Welcome to Kunta Gautam, now a regular
Nursology.net Blogger and
Management Team member!
Why is there so much rumor that Nurse Practitioners (NPs) are not quite well prepared for what they have undertaken the education and training for? I am a nurse practitioner working as a front line provider and my blogpost may be biased or opinionated, but I must highlight some salient features that NPs contribute to healthcare, most notably when our practice is founded on a nursing theory.
- 1965- Dr. Loretta Ford and Dr. Henry Silver developed the NP program at the University of Colorado.
- 1968- another NP program developed by a nurse & physician team in Boston.
- 1974- Burlington Randomized Trial study found NPs conduct appropriate referrals.
- 1985- American Academy of Nurse Practitioners (AANP) was established, collaborating internationally for NPs’ professional development.
- 2019- there were more than 270,000 NPs in the U.S.
- 2023- Nurse Practitioners have flourished to 355,000 nationally in the U.S.
History reflects that the NP role evolved in 1965. But why are we being treated differently in healthcare? NPs struggle to fit-in in both nursing and medical domains completely. They are sort of outcasted from the proper nursing umbrella, which could be because they have a license to practice, which is a “medical model.” My viewpoint might be a little biased because this is my personal experience working in tertiary care level specialty areas in the hospital setting. I did not feel welcomed and supported by nurses when I made rounds for inpatient consults in the hospital. I was a new graduate NP working in a specialty area, performing multiple roles: outpatient clinic, inpatient consults, and initial workup on ER admissions. The most common question that I was asked during inpatient consults by experienced nurses was: “Why are you working as an NP when you can easily make more money as an RN?” I would say the best answer I could possibly say being mindful of trying not to hurt anyone’s feelings. For me, it was a path in my career; I never counted the money, simple as that. However, over the course of time, I have seen positive changes related to this problem. RNs are more accepting and trusting of their NP colleagues. And, as a profession, that gives us (nurse practitioners) a sense of unity, strength, and belonging.
With over 13 years in an NP role and five years as a clinical preceptor, I see that our practice is an excellent way of serving humanity with complete independence and authority. I have been an NP in all areas: 3 years in specialties in a hospital setting, 7 years in primary care practice, and three years in urgent care practice. I have been through different challenges. I was thrown in the spot to make clinical decisions; which was sometimes nerve-racking, but I never gave up. I did my homework and, at the same time, never stepped back from asking questions. I had my learning curve; I made several mistakes. However, I had collaborating physicians and others who helped me learn and grow and made me feel like I was making sound decisions. I still learn, refer to resources when I need to, and seek consultation. As an NP, depending on our clinical area, we must communicate our expectations with the healthcare team. We should be allowed to make mistakes, learn, collaborate, and grow in a healthy environment as a team.
Nurse Practitioners have a unique trajectory that does not fit into other hats: nursing, medical or other allied health professions. Here are some key points that describe us, along with some recommendations for new graduate NPs:
- Nurse Practitioners complete three years of the graduate program (+/-, depending on various universities) after completing four years of Undergraduate degree BSN. They take advanced pathophysiology and advanced pharmacology courses.
Recommendation: This is only school education to build your foundation. Never stop learning. You will learn more in the real world.
- The term “mid-level” does not define who Nurse Practitioners are. We were not given this terminology from our nursing profession, and I would reject any other terminologies that define our role besides what our profession has given us. Extensive lectures, clinical hours, and training invested in preparing an NP are not mid-level people who are considered to be on the back seats, making discharge summaries and doing more “clerical, clinical work.” A competent NP would not stay longer if they were treated as a typewriter or a phone caller. In this were the case, the hospital would be at a loss, losing a graduate-level prepared professional workforce, who could have been utilized to their maximum potential at less expense.
Recommendation: Know your worth. Study, build yourself, and prove your worth to others around you. Do not let others define you as mid-level. Correct them politely to call you a Nurse Practitioner or a Provider. Do not go with “mid” or “sub”.
- Nurse Practitioners know their skills, knowledge, and scope of practice. The prescription authority is earned from demonstrating expertise and accountability in the provider role. They abide by two licenses, RN and APRN, and in conjunction with both the nursing and the medical boards.
Recommendation: Own the prescription authority given to you and what you have worked for.
- Nurse Practitioners have a different lens through which they view those they care for. When they wear a medical model hat and give treatment recommendations, they also listen to other areas of health issues. They practice a medical model which is solidified with a nursing foundation.
Recommendation: Never lose the site of holistic nursing and our core values. Remember, the unique gift you have is the combination of nursing and the medical model. Always, proudly stand out from the crowd by bringing this quality in you.
Nursing theorist, Patricia Benner, provides detailed stages of clinical competence in her book “From Novice to Expert” (1984). This theory describes how expert nurses develop skills and understanding of patient care over time through proper education, application of knowledge, and patient experiences.
Applying Benner’s stages of clinical competence in the NP model of care
- Stage 1 Novice: The NP student learning and gaining knowledge is a novice. At this stage, students are building a foundation with advanced pathophysiology and advanced pharmacology. In addition, they are learning basic steps like HPI, review of systems, physical examination, assessment, and plan. (Similar to the SOAP format seen in BSN programs).
- Stage 2 Advanced Beginner: These are new graduate NPs. They have a great deal of knowledge but not yet experienced enough to treat patients without guidance or supervision.
- Stage 3 Competent: These NPs have some mastery of advanced practice but may not have practice efficiency. However, they can make diagnoses more accurately than advanced beginners.
- Stage 4 Proficient: At this level, NPs can make clinical decisions in more than one area. In addition, they can handle multiple health problems in a patient. For example, a patient with an asthma exacerbation, ear infection, and diarrhea/vomiting.
Stage 5 Expert: These are NPs who are independent in their practice with minimal consultation needs. They can address uncommon challenges that come into the practice and be flexible as the situation demands. They can also handle emergency situations like active seizure management, respiratory distress, etc. In addition, they can identify subtle signs of illnesses that could be missed.
The purpose of this theory, as Benner states, is that these levels reflect a movement from past experiences of skills acquisition and moving forward into more concrete experiences. Transitioning from bedside to a provider role is an entirely different role description. A new graduate NP has to start the provider journey from the stage of being a Novice to an Expert. It requires a solid foundation to thrive, own the responsibility, make clinical decisions, and stand firm with the rationale for making that decision. Dr. Benner found that improved practice depended on experience and science, and developing practice skills was a long and progressive process.
I would highly encourage all new graduate nurse practitioners to embrace the program’s intensity, choose a study method that works for you, and learn every step during the clinical experience without missing any single step. I would encourage students to ask questions to their preceptors or supervising clinicians and not hesitate to say, “I would like to learn more” Remember, nobody is born an “expert.” We need to overcome the fear mindset and go through the learning curve. You will be surprised that everyone will be willing to help you grow if you seek it out. If the area you practice is not healthy for your growth, I suggest you move on and explore and find the right fit where you meet your passion and growth.
I would appreciate thoughts, comments, and constructive ideas.
Benner, P. (1982). From novice to expert, American Journal of Nursing, 82(3),402-407.
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley Publishing Company.
Nurse Practitioner and AANP History. Retrieved from https:// www.aanp.org/history