Precepting a student with a shockingly low-credit program

[Febrifuge]

EDITED: See below. In short, this could be titled "Student Needs Not So Many Clinical Hours, It Seems To Me Based on What I Know at This Point."

 

I've agreed to take on an NP student for the fall semester. This person attends a state school somewhat nearby. Sometime between early September and early December, she needs 150 hours. Actually 100, since it sounds like the program person and the student have agreed she'll do 50 hours in the student clinic.

 

Even with my part-time schedule, with 2 weenie 4-hour evening shifts per week and regular shifts every other weekend, I calculated we could do about 195 hours in that span of time. I know I'm a grumpy old man, but unless I find out she is also doing something else that feeds her DNP-level education at the same time (and by that, I don't mean working as an RN, sorry) I'm getting ready to get my frowny face on about this.

 

I routinely did six-week rotations at 35-45 hours per week when I was in school, so 100 hours is less than 2 weeks worth of training, as far as I'm concerned. And it's not like my clinic is terribly busy, so at least some of those hours are going to be spent chatting about this and that, and not seeing patients at all.

 

Curious, I looked up the DNP program in question: http://www.uwec.edu/academics/graduate-programs/dnp.cfm

 

<EDIT: Later in the thread, this caused some trouble. Basically, it's more like 75-ish credit hours from BSN to DNP, and I haven't looked into how other programs in that university system compare, credit-wise. I really wish I had stuck to the 150-hour clinical thing, but if I deleted this now it would all look weird and make no sense.>

 

Check out those Core Courses. Take a BSN, give him or her 30 hours (!) of classes, then set them loose for another 20 credits of clinicals, and hey presto, you have a clinician. One who, in Minnesota, doesn't even need physician oversight anymore. Damn, I had 22 credits per semester in summer, in my program. 26 to 28 credits per semester during didactic year.

 

I've recently resolved to up my game in terms of precepting, so I'll do what I can to give this student a useful and interesting experience, but part of me thinks I will be grading very stringently and maybe even assigning a bunch of extra work, just because I'm amazed at how few credit hours - and how few clock hours - are involved at all steps of the process here.

 

I'm also not crazy about how you can't use the Web to see what the required rotations are, how long they last, how many credits are awarded for each, etc. It's not just me, right? That's weird? Please tell me that's weird.

 

For comparison, here's my school's page: http://www.rosalindfranklin.edu/Degreeprograms/PhysicianAssistant/Curriculum.aspx

 

Aside from just venting, I'm also wondering about advice. Those of you who have precepted students for a while, do you have any techniques you like to use to make sure they're learning? I've had 4 or 5 NP or PA students over the past few years, but I'd like to kick it up a notch and get good. Since my schedule is so light, I feel like assigning homework and making them do little presentations is totally fair game. I'm still a fairly "cake" rotation, I have no doubt of that.

[rpackelly]

There are more NP programs like this than you describe.   The NP party line is that their experience as RNs makes up for the lack of clinical training.  However a number of the programs now are direct entry, meaning you have a bachelors in something else, get an RN in one year along with a BSN, and then do a masters or dnp the second year with didactic and clinicals occupying 12 months.   Additionally, clinical hours required now for a BSN are only 600 and a number of them can be "simulated".  As you have noted frequently the NP clinicals are 1) not full time and 2) the students generally follow NPs instead of MDs.   The didactic courses are also taught by NPs and not MDs.   And yes, then you can be called doctor and be independent in 20 states.    There is also no uniformity in terms of terminal exam (like PANCE), depending on specialty, and no uniform accrediting agency that makes detailed site visits, like ARC-PA.  As you know, both the NCCPA and the ARC-PA have physician and physician specialty membership as commissioners, and the NCCPA collaborates with the National Board of Medical Examiners,  but the two major nursing accreditation agencies are composed of nurses.   There is one nursing certification test for DNPs that almost no one takes that has medical oversight, but that is new and so far completely voluntary.  I know many fine NPs (really I do)  and believe that competency can be achieved by more than one method, but......

 

Our profession needs to not downgrade another profession.   But, we need to make sure the public and lawmakers have enough valid information to adequately compare apples with apples and oranges with oranges.

[Febrifuge]

Our profession needs to not downgrade another profession.   But, we need to make sure the public and lawmakers have enough valid information to adequately compare apples with apples and oranges with oranges.

 

Well-said. I've said repeatedly and often that out in the "real world," the vast majority of NPs I've known and worked with have been great. Very good clinicians, no issues I've been able to see. But on paper, wow, the training is put together in a way that makes the MDs and us PAs look over-qualified, I guess.

[EMEDPA]

I have precepted md resident, pa and np students for years. I try to simulate a new job environment for students. I show them around, give them a chart, and tell them to go see the pt. they do the full H+P and come up with a plan. I review pertinent features with the pt and walk the student through every procedure once or twice in a "see one, do one" type format. I also ask the program specifically to send me students with an interest in em and urgent care. I pimp them on meds, disease processes, etc and ask them to come up with differentials. by the time most of them are done they are in a position to apply for an entry level position in em or uc.

[ChronicSG]

I am glad to see that teachers of your caliber are precepting future clinicians. I agree that TOO MANY NP programs are providing such a minimal amount of hours and believing that this prepares the graduate to Dx and treat patients. I know that medicine and learning continues after graduation, but you need a good foundation for the results to not be catastrophic. It's one of the reasons I'm honestly debating PA school over NP school. Also because of the fact that I don't need to get another certification from the board of nursing should I want to leave hospital based medicine and return to primary care once I am also a "grumpy old man." hahaha

ChronicSG RN, BSN
 

[EMEDPA]

FNP is ok for fp or urgent care, if those 2 options appeal to you. I think most FNP folks, however are not prepared to do EM right out of school.

[SocialMedicine]

could this be an NP going for a DNP ? I understand some DNP programs require clinical with research projects attached. Like work in an ED clinic and conduct a QI project. That type of thing. 

[db_pavnp]

I've dug around the page suggested here and looked at the core courses.  I don't feel that the page is very clear about it, but those courses are the 800 level DNP courses only.  Those are not the core courses for the initial NP or CNS Master's programs.  I would look further before posting, but before the sharks get going...

[rpackelly]

Some DNP programs require a masters, others do not (BSN-DNP).  The one mentioned here will accept both, which is common......the BSN prepared student requires more credits, the MSN one less.  So it is not fair to say that students on entry are already NPs, some may be, others not. 

[rpackelly]

The program in question, if one is pursuing the NP to DNP track, requires 550 hours of clinical practicum at the masters level, which is what NP certification generally requires.  It is very possible for someone with a BA to enter a directly-entry MSN program, do 500-600 hours in the RN track, graduate after one year with a BSN, then do an additional 18 months in the MSN track with 600 more clinical hours.  That is 1200 lifetime patient care hours on graduation as an NP, less than many PA programs require as HCE on entry. 

 

Back in the day, the old UC Davis FNP/PA Program required less clinical hours for NPs (I think 1600 to 2000 for PAs) BUT required nurses to have at least two years of post RN experience, one of those in an ED or a unit.  That made sense.  After education together both the PAs and the NPs were about equal, because the PAs had prior HCE as well (at least 2000 hours, many as IMGs or medics).   And, at that time, RN entry level training required many more patient care hours as well.   Reviewing some old transcripts of diploma trained nurses for admission, it was not uncommon for people to log 3000 to 4000 hospital hours during those three years.  So many NPs trained back in the day really had the hours that they speak of today, but the current reality for many professions involves higher degrees and less clinical hours at graduation.  Medicine, in terms of residencies, is following that paradigm as well, so much so that there is a trend to add years of fellowship, because entry level residency trained MDs cannot do the procedures or make the decisions that a graduate of the past was once comfortable with (this is especially true in surgery and has been the topic of a number of recent studies).  Malcom Gladwell's rule that at least 10,000 hours of time on task  is required for mastery is likely true. 

[db_pavnp]

Between the subject line and the original post, this thread cannot be saved and should be deleted.  The OP characterized the program as a 150 hour doctoral level nurse practitioner program generating a clinician and that is not the case at all.

[sk732]

I'll start off by saying I'm not slamming NP programs, however, I still think there is an apple vs orange comparison going on here - our (I mean the global our) HCE hours/nursing hours are not really the same as clinical training hours at an NP/PA level.  They are hours of exposure to sick people in the environments we were trained to be working in.  However, clinical hours in a PA/NP training setting are actually a lot different - for they're meant to be exposed at a different level, with wider expectations of DDx's required and the actual clinical decision making based upon repeat exposure to both the illnesses and variety of clinical courses of them, and YOU utilizing the treatment guidelines that YOU have to decide upon based on your diagnosis/differential(s) and current clinical thinking.  For some, much of their previous experience is in algorhythmic or standing order based treatment, vice actually sitting down and critically analyzing what is wrong, what can go wrong, pros/cons of various modalities/drugs, etc.  I'm amazed at many crusty old ED nurses with eons of experience that still don't appreciate some basic areas of physiology or pharmacology/pharmacodynamics with certain drugs, diseases, etc - they're quick to quip about why I'm not doing something or why I did something else but have no grasp of what's actually going on.  They also tend to shotgun labs vice pick and choose what should be ordered based on what YOUR findings are - gets a little expensive in some bean counting environments.  This stuff comes with clinical experience and clinical decision making experience, which are two very different things. 

 

Another analogy is the jump in responsibility from an intern to a junior resident - they're busy doing procedures, learning ways of doing things and putting them into action...but come July that next year, they are the one making the decisions vice acting on them and now comes a whole new can of worms confidence wise that has to be opened.  Much like that very first prescription I wrote after graduation that had MY NAME ONLY on the bottom without a countersignature - I actually thought for a few minutes before signing it, since I was legally responsible for my decision...I remember it vividly, it was a prescription for penicillin.  You'd think that's something I couldn't mess up much, but I had a (long) moment of self doubt.  Same with that first consult - definitely stepped back a second to make sure I wasn't making myself look like an asshat, despite having done these up countless times before, but me not actually signing it.

 

Those extra hours can be not only life saving, but also time saving in the end, just due to the levels of exposure and comfort you get, which makes you a better and more efficient provider.

 

SK

[db_pavnp]

Check out those Core Courses. Take a BSN, give him or her 30 hours (!) of classes, then set them loose for another 20 credits of clinicals, and hey presto, you have a clinician.

 

Just to reiterate, the website is really strange, but from my digging:

 

The only Practitioner program they offer is a DNP.  They do not offer a master's level NP.

A BSN applying to the DNP will go to school full time for three years, perform 1100 clinical hours, and obtain 73 credits.

https://www.uwec.edu/academics/college-nursing-health-sciences/graduate-programs/doctor-nursing.cfm

 

Based on this information, the original poster should reevaluate their post.

[EMEDPA]

Just to reiterate, the website is really strange, but from my digging:

 

The only Practitioner program they offer is a DNP.  They do not offer a master's level NP.

A BSN applying to the DNP will go to school full time for three years, perform 1100 clinical hours, and obtain 73 credits.

https://www.uwec.edu/academics/college-nursing-health-sciences/graduate-programs/doctor-nursing.cfm

 

Based on this information, the original poster should reevaluate their post.

so basically 1/2 of a bs level pa program....if you look into the "fact sheet" you will see that students must maintain a "C" in every class to graduate. most graduate programs (both pa and np that I am aware of) require students to maintain a "B" avg.

Feb has reasons to question this program. (not all NP education, this program specifically).

[db_pavnp]

Can you find evidence to suggest that credit hours between programs are equivalent?  I can only find reasons they are not equivalent.

[EMEDPA]

Can you find evidence to suggest that credit hours are equivalent?  I can only find reasons they are not equivalent.

why would a clinical hour be any different for a pa vs an np? 1100 hrs is what they stated. a typical pa program is 2000+ clinical hours at any degree level. by my math that's about 1/2. a lot of pa programs are 150+ credits.mine was around that.  today it's 122 hrs after removing a few rotations:

http://catalog.drexel.edu/graduate/collegeofnursingandhealthprofessions/physicianassistantcon/#degreerequirementstext

[UpRegulated]

Despite the critique of NP education, most PA's will readily admit they work alongside NP's who are excellent clinicians.  If our preparation is so terribly inadequate, how can that be?  Outcomes are what matter, not clock hours.

 

Hours cannot be equally compared with an NP vs. PA, and racking up hours says nothing to the quality of those hours.  A PA and an FNP (for example) will both graduate with between 600-1200 hours of family practice.  PA's have other specialty rotations, but the post-graduate utility of those hours are debatable, depending on specialty chosen, and especially given how common it is for many of those hours to be largely observational hours based on what I've read, heard, and seen.  In my NP program we needed a minimum number of hours and a minimum number of patient contacts to progress, with pt. contacts being defined as me seeing the patient, taking the history, developing differentials, and developing a plan completely on my own before presenting the patient to my preceptors.  BTW, every preceptor I had was an MD except one who was an NP with 10 years of experience.  My 1 clock hour in a family practice clinic was worth far more than 6 hours standing HOB or in the corner of an OR watching an orchiectomy and an AVR.

 

The fact is, someone who is bright, motivated and has a reasonable amount of solid RN experience, NP education at many schools is perfectly adequate to train an entry-level clinician.  But in most cases, it takes at least two of these things (intelligence, motivation) and often a reasonable amount of RN experience to make a good clinician.  Those lacking in any one of these areas will most likely either fail to graduate, fail to pass boards, or fail to get a job.  Those that do somehow get through and get a job are often working as nothing more than glorified RN's, or work as clinical instructors to undergraduate nurses, or return to the floor.  If you work alongside an NP, you are working alongside someone for whom 600-1200 hours was sufficient for them to "get it."

[db_pavnp]

why would a clinical hour be any different for a pa vs an np? 1100 hrs is what they stated. a typical pa program is 2000+ clinical hours at any degree level. by my math that's about 1/2. a lot of pa programs are 150+ credits.mine was around that.  today it's 122 hrs after removing a few rotations:

 

Clinical hours aside, my question was what evidence do you have that the credit hours are equivalent?

 

I attended a BS program that was affiliated with multiple mid-Illinois colleges.  Depending on what college you attended, the credit assigned the program differed.

 

So that's my evidence that a credit hour does not equal a credit hour.  It is simple for an institution to inflate credit hours.

 

Regardless, I will reiterate that the subject line and the original post misinterpreted the program website and is sufficiently flawed to warrant retraction / deletion.

[Febrifuge]

Wow, this really did blow up. I didn't mean to start anything, I swear!

 

I don't consider NPs to have inadequate training; I do have some misgivings about how the educational programs are structured, and how much time people get to spend in their clinical training. (I also have some anecdotes about the quality of that training, but that plus $5 will get me a latte, so fair enough.)

 

I have no doubt that the really awesome NPs I've worked beside are go-getters, and made the most of their training. I also feel that if they had been better-supported, like I was, then maybe they would be even better. And the idea of some graduates who can't hack it settling down into administration roles doesn't actually reassure me, strangely. But anyway: back to the situation.

 

The student in question has a BSN, but is not a Master's level NP (or any sort of NP in fact). She will have a DNP at the end. My issue really is pretty specific, and focal, based on the idea that apparently 150 hours in a semester is what she needs.

 

I know she's an RN. Is she a super-motivated really smart RN with a ton of great experience? I hope so. I don't know. She doesn't start the rotation until Fall semester. Even if she's awesome, though, I struggle to understand how 150 hours hanging around in my clinic (I just finished a shift with fewer than 10 patients in 5 hours, btw) is going to "top off the tank" and get her all set to go and do this job after graduation.

 

I do plan to treat the rotation as sort of a new-clinician environment, and assess how the student is doing with the thought processes involved in being an independent practitioner. I have to admit, knowing what I know now, I might be a little tougher on the student, and hold her accountable for more knowledge. I hope no one has an issue with that.

[Febrifuge]

 

Regardless, I will reiterate that the subject line and the original post misinterpreted the program website and is sufficiently flawed to warrant retraction / deletion.

 

Why? Because someone's feelings might be hurt? If there's clarifying information that puts it in better perspective, that will be in the thread too. Lay it on me. Educate me. Illuminate the discussion. Point me at what I don't know yet.

 

I stand by everything I write, and I only edit it when it's not what I meant to say. If it turns out later that I was wrong, I'll say that at the appropriate time and place/ in another post. What I don't do is delete something so I can pretend I never said it.

 

Settle thy jimmies, dear colleague, that they may be un-rustled.

[db_pavnp]

EMEDPA and I have both linked the actual requirements in the thread already.

 

Why did you not read the thread and the linked material before posting two more times in succession?

 

You have misinterpreted the program.  And continue to misrepresent it.  And with the jimmies comment, you are straight trolling.

 

The information countering your misinterpretation of the website has been clearly posted.  There is no such program as you have outlined.

[Febrifuge]

Both post-masters (MSN-to-DNP) and post-baccalaureate (BSN-to-DNP) options are offered. The MSN-to-DNP option includes an advanced clinical practice option (for nurse practitioners or clinical nurse specialists) or a nurse executive option. The BSN-to-DNP option includes adult-gerontologic primary care nurse practitioner, family nurse practitioner, adult-gerontologic clinical nurse specialist, and nurse administrator/nurse executive (adult-gerontologic or family population focus) options.

 

For post-masters students, the DNP program includes 29-30 credits of nursing courses offered over three terms (summer, fall, and spring) and two years of part-time study. The post-baccalaureate option consists of 68-73 credits with full-time (three year completion) and part-time (four and five year completion) plans available.

Source: https://www.uwec.edu/academics/college-nursing-health-sciences/graduate-programs/doctor-nursing.cfm

 

NOW it has been clearly posted.

 

The reason I went off was because the suggestion I should delete the thread, or my originating post, is straight-up offensive. That's not how professionals do things. This board is a resource for PAs, and people interested in the profession. It's not exactly a record, but especially when the conversation is moving fast and people are responding, changing the text of what they responded to seems to me to be dishonest.

 

I'm happy to have been shown that I was wrong about this DNP being a bachelor's plus 30-50 credits. That being said... you know what, I'm going to leave this alone for a minute.

[rpackelly]

OK, in the original post you asked for teaching suggestions, and this summarizes and gives further references for clinical preceptors:

 

http://www.aliem.com/pv-card-one-minute-preceptor-nerds-mnemonic/ 

[Febrifuge]

Thank you!

 

Also (and this is to everyone), putting aside credit hours for the program -- because it's true, the hours themselves, compared to credit hours for the same university system's BSN, or graduate degrees in other areas including PA, might be just fine -- I'd like to re-focus on the clinical side. I'll be looking into whether this is a student who simply came up a little short on another rotation and needs to round out the total, or if 150 hours for a semester really is all they need. I'll update later with what I find out.

[Mercury00]

As a career changer with social science undergraduate and graduate degrees, I researched PA programs, NP programs and medical schools when I decided that I wanted to transition into healthcare. I have since ruled out the NP route due to the shockingly low number of credit and clinical hours required by many programs. I find it somewhat disturbing that as someone without any experience in healthcare, that I could obtain my BSN in 1 year of full time study or complete a masters clinical nurse leader program in 2 years of full time-study and then be accepted into a DNP program without ever having worked as a nurse. While some DNP programs require at least 1 year of experience as an RN prior to admission, some do not, including the BSN-to-DNP program at the University of Wisconsin Eau Claire.

 

Further examination of the University of Wisconsin Eau Claire's nursing program produced sample plans of study for the BSN-to-DNP program. This program can be completed in three years of "full-time" study. "Full-time" study requires taking 0-4 credit hours every Winter and Summer session and 8-11 credit hours every Spring and Fall session. Of the 73 credits needed to complete this program, 14.5 are considered clinical credits and each clinical credit equals 75 hours of clinical practice time, for a total of 1087.5 clinical hours completed over the course of 3 years. This program can be completed without doing clinical rotations during the Winter and Summer sessions and no more than 225 hours of clinical rotations in any given Spring or Fall Session. This is a ridiculously low number of credit hours and clinical rotation hours compared to PA programs and medical school. Someone like myself could complete this program without ever having worked full-time as a nurse and after only 1087.5 clinical hours be considered competent enough to work as an FNP without any oversight in a number of states! Honestly, that's a bit terrifying.!

 

If you would like to view the sample plans of study for yourself, they can be found here: http://www.uwec.edu/academics/college-nursing-health-sciences/graduate-programs/doctor-nursing.cfm.