Hello fellow Registered Nurses (RN) who are contemplating the Nurse Practitioner (NP) route in furthering your healthcare career. I have been an NP since 2015, specializing in cardiology, after being an RN for 27 years. I recently retired in August of 2020, as I was witnessing a decline in healthcare that was very concerning to me. Healthcare now is not what it was when I started nursing school in 1985. So much of the education is online and not in person. One cannot practice effectively in healthcare if the bulk of the education received is through a computer screen. This is how much of the NP education is now being given and makes hands-on experience as a nurse – in advance of pursuing an NP degree – so critical. If you are indeed considering this path, I have some advice for you and questions for you to ponder.

When you graduate from a nursing program it’s a HUGE accomplishment, then come boards! Talk about stress! OMG! You find out you passed boards and are so elated thinking “yes I am a nurse!” You think you’ve learned everything you need to know and are ready to take on the entire medical field, ready to be a team player, make a difference because getting through school and boards was the toughest part. Right? Wrong!

Starting as an RN at the bedside in a hospital is step one! You have enough experience to take vitals and do an assessment. What happens if something is wrong, vitals are off, lungs aren’t clear, extremities are edematous, what do you do because NOW you are the nurse, not the student? This is the start of your “professional experience” and you will have to go through this experience, plus many others, for 5 to 7 years to be considered an expert in the nursing profession.

In addition to your assessment skills and ability to administer medications and treatments, you will also need to be able to incorporate lab results, diagnostic imaging reports, and perform patient teaching so the patient truly understands their disease and why the treatment plan is what it is. Sounds doable right? So then the next step is to become an NP because your attitude now is “I can do this and I can do what doctors do.” Problem is many nurses don’t want to be at the bedside for 5-7 years because they are tired of being told what to do or yelled at for doing something wrong or not in a timely manner. Your evaluation from your manager states you aren’t meeting the standard, or you are meeting the standard but you think you are exceeding the standard. You get frustrated and your ego is hurt because you think you are better than what others think of you. So you decide to leave the bedside after 2 years and go back to school to be an NP because you know this is going to be easier. Easier for who? You? The patients?The doctor(s) you work for/with?

Throughout my nursing career I was always thinking about Patricia Brenner’s Novice to Expert Nursing Theory, it is spot on with the Five States of Clinical Competence. Stage One is the Novice, you’re first starting out and you have limited knowledge of what could happen to the patient. Stage Two is the Beginner, which encompasses your first 1-2 years in practice at the bedside. During these formative years you will gain experience from which you can draw from to your further practice. Stage Three is Competence, you can now organize, prioritize, and are able to be flexible with patient care. Stage Four is Proficiency, this is the stage where you are not only able to react effectively, but you are a proactive patient advocate. Stage Five is the Expert stage, this is where you know what needs to be done, can implement care effectively and efficiently, and have the ability to be intuitive because you have experience from which you can draw on. This stage is where you become an effective leader and teacher to other nurses.

Why did I just go through that? What does it really mean? It’s a great tool that I have always relied on when I have either started on a new unit or when I have been teaching students or orienting new employees. In my experience I feel that it is of utmost importance for RN’s wanting to become NP’s that they are competent in bedside nursing before they become an NP. Experience at the bedside is priceless, which I think we can all agree on, as we know so many things are not textbook. You can’t read about intuition, it comes with experience and the only way you get experience is by working. You need to be an important part of the healthcare team which means getting along with doctors, nurses, pharmacists, respiratory therapists, physical therapists, etc. This takes years, 5-7 at least. Any less than that is not going to benefit you, the doctor, the patient, or any of the other entities involved.

We all know medical school is different from nursing school. Doctors are trained to be the leaders of the health-care team. It is who nurses go to for direction on tests, medications, therapies. Doctors have the most experience on the healthcare team as we know from all of their years of schooling, residency, and fellowships. Nurses on the other hand are mostly Bachelor’s prepared now which means 2 years of general education and then 2 years of nursing and theory. Therefore it is imperative for RN’s to work at the bedside for at least5-7 years before going back to school to obtain the NP degree. These questions are ones that should be answered with honesty and integrity before you decide to pursue the NP route:

• Do I feel confident in my one on one assessment skills of any patient I encounter?
• Am I able to have an idea of what tests and medications may be ordered when I call the doctor to let him/her know the status of the patient?
• Am I afraid to ask questions if I don’t know?
• Am I able to handle constructive, as well as destructive, criticism?
• Am I ready to take on this new challenge as I know it will take 5-7 years to become an expert in this field?
• Do I feel I can treat patients competently? Am I willing to continue to learn even when I get upset if I am wrong?

Remember that, in most circumstances, as an NP you are functioning under the license of the physician you are with. Do not put him/her in a bad spot. Be confident and competent for the physician as well as the patient. Make sure you are not afraid to ask questions or clarify something you are unsure about. The physician, as well as the patient, will be glad you did.

An unpopular opinion, but one I will state anyway. New NPs have no business having “Full Practice Authority” or practicing unsupervised. This is dangerous for patients, and puts them (and the NP) at significant medicolegal risk.

Best wishes to those who choose the journey to being a well respected NP! It takes years and it takes a lot of determination. Remember you are a part of a healthcare team and others are relying upon you, don’t let them down.