31 Comments

Nurse practitioners and physician assistants work in very similar settings and in many cases are even used interchangeably. In the emergency department where I work, for example, NPs and PAs are hired for the same positions without a preference among management for one over the other. Although these medical providers work alongside each other performing the same job responsibilities and with similar scopes of practice, there are a few ways the nurse practitioner and physician assistant education looks different.

When I graduated from my NP program and accepted my first nurse practitioner position in a walk-in clinic, I often found myself wishing I had become a physician assistant rather than a nurse practitioner (gasp!). While my sentiments have changed, I do think there are a few benefits of the PA approach to education. As nurses we have a lot of pride in our profession. But, this shouldn’t leave us closed off to accepting best practices from other areas of business and medicine.

Nurse practitioner programs would do well to integrate the following approaches commonly used in educating physician assistant:

1. Focus on procedural skills and diagnostic tests over theory

As a nurse practitioner student I felt that I spent an excessive amount of time writing essays on nursing theory, completing group projects and sitting in lectures discussing content unrelated to direct patient care. I can appreciate that understanding the foundation of one’s profession is important. But, perhaps a brief overview would do.

In contrast, physician assistant program curricula often contain courses titled ‘Introduction to EKG’ and ‘Clinical Radiology’. These courses are specific to essential clinical skills, skills often lacking among new nurse practitioner grads. Integrating similar courses into the nurse practitioner education would help level the new grad NP learning curve.

2. More hands-on clinical hours

Sure, as an NP student I found clinical days exhausting and sometimes stressful. There’s nothing worse than a day of hands-on learning followed by the need to return home only to cram for an upcoming test or put the finishing touches on a research paper. But, frankly, I could have used more of these stressful days during my training.

Nurse practitioner programs typically include somewhere around 650-850 clinical hours. Physician assistant programs, in contrast, require students to complete closer to 2,000 hours of hands-on clinical training. This added experience is noticeable in the first years of practice. The playing field eventually levels out, but ramping up the number of clinical hours required of NPs would benefit new nurse practitioners.

3. Transparency in objective program data during the admissions process

The other day I was perusing a few physician assistant program websites. I was caught a bit off-guard when I noticed nearly every program listed pass rates on the NCCPA certification exam for their graduates. In contrast, nurse practitioner programs guard their stats a little more closely. Yes, some NP programs list certification pass rates for recent grads but most do not. If students think to inquire about such information during the admissions process, many schools will reveal their scores. I have encountered a few nurse practitioner programs, however, who refuse to share data regarding NP student certification rates among their graduates.

I recommend that every NP program applicant ask schools of interest what percentage of graduates pass the certification exam on the first attempt. Wouldn’t it be nice if aspiring NPs didn’t have to dig for this information, but rather it was posted outright?

I don’t mean to get down on the nurse practitioner education. I feel that my NP program prepared me well for practice. But, like most things in life, it could have been even more effective with a few modifications. Looking outside of the nursing realm to how other professions educate their students can lead to valuable insight and improvement.

Where do you think nurse practitioner programs stand to improve?

 

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31 thoughts on “3 Ways NP Programs Should Be More Like PA Programs”

  • Colette Russen RN, CEN, FNP student says:

    One of the reasons PA programs require so many clinical hours is because many of them have never even touched a patient. NPs, on the other hand, have already gone through hundreds of hours in nursing school and thousands at the bedside as nurses. NPs are expected to come to the program with honed assessment skills so that they don’t need 2000 hours. (This is also why I don’t think NP schools should accept students with no bedside experience.) I had over 800 clinical hours for my RN, and over 75,000 hours in my years as a bedside nurse when I began my FNP. I’m currently in clinicals with two PA students who are still learning how to assess breath sounds, something I’ve been doing for 10 years. However, I do agree that there is too much theory and not enough practical experience in NP programs. I spent $30,000 on my masters and had to spend thousands extra to learn to suture and splint. No ED where I live would hire me without knowing I could perform these skills.

  • Lorrie White, FNP-C says:

    I so agree with you. My NP program left me feeling unprepared for my first job. I did almost no procedures during my school rotations; I gave about 6 knee injections and that was it, nothing else. I interpreted no x-rays and only an occasional lab, but I do want you to know that I can write an awesome 15 page paper.
    I’ve been working now for 16 months as an FNP in a Wal-Mart walk-in clinic and I still have no skills. We do no procedures here, we follow no chronic conditions, do no lab work or anything. It’s just me and my MA. I see people for rashes, colds, flu, UTI’s, etc., only very minor stuff.
    I’ve wished many times that we had done rotations in school like the PA’s; they do orthopedics, emergency medicine, cardiology, dermatology, endocrinology, nephrology, etc. along with the fundamentals of primary care. I have no orthopedic skills, I can’t examine an elbow or a knee to save my life; I got no ortho in school. I even took the ortho class at the national NP convention a few years ago but got nothing out of it. I would kill for an ortho rotation, I really would; someday I will need it. I wish I would have applied for an NP residency.

  • I would have preferred access to cadaver studies in my NP program at a top rated NP school in northern California. I worked in an Orthopaedic Dept for 15 years in my NP career, and would have been better prepared by training with real bodies.

  • Dave Mittman, PA, DFAAPA says:

    Excellent blog. There is much we can lean from each other. NPs and PAs must be close colleagues for both to do well.
    Dave

  • I keep thinking the same thing in regards to less theory, more practical skills in NP school. I write pretty well so it’s not that I’m afraid of it, but I’d like a program that’s more skill-heavy. I’m still evaluating programs (visiting Vanderbilt this weekend actually!), do you have any thoughts on which direct-entry programs might lean a little more heavily toward clinical over theory? It’s a really hard thing to get a feel for.
    Thanks!
    Alice

  • Im in my final clinical rotation in an acute care NP program and I feel very comfortable. I have done 2 er rotations and have done tons of suturing and even put in a chest tube. I can’t wait to start my practice.

  • Dave Mittman, PA, DFAAPA says:

    Colette: All of my classmates were RNs, EMTs, medics and military corpsmen. Now physical therapists and pharmacists also are in PA school. All PA schools require prior healthcare experience and believe me they look for it.
    I would agree among newer NPs and PAs the prior experience level has gone down. That is a trend that comes as degrees go up. That being said, PA was always a second career for most who chose it. We do have hands on experience.
    Dave
    Please do not

  • Lisa Patker FNP says:

    All good comments! I agree about the theory – too much. Actually, I am disappointed that the DNP programs have so much theory in them. I have resisted in going for my DNP for this reason. I also think that more time on practical skills including both the didactic and hands on learning in all of the areas commented on would benefit our argument for full practice authority in all states.

  • Lori Ann Soteros, FNP-C says:

    This is a great conversation point. I certainly agree about less theory, although I have to admit, I learned a lot from it that has helped me in round about ways. We all (NPs and PAs) must have valid points as individuals with varied experience levels. Personally, I have 25 years working with women and children, mostly hospital OB.
    After I graduated, I started my own practice specializing in IV Nutritional Therapy and also just accepted a part-time position at a Family clinic where I am the only provider. I have a hand full of providers I can call for guidance if I need to. I was concerned that I wouldn’t know enough about family practice, but as I am just completing my second week in the clinic, I’m surprised at how well I’m doing and how much I really do know! Knowledge I struggled to find during the National Exam is flowing out much easier now (thank goodness).
    My NP clinical hours as a student was primarily with very experienced MDs specializing in Internal Medicine and Pediatrics. I happened to know the doctors from working in the hospital with them. They wouldn’t have taken me on as a student if I didn’t already know them so well. One thing that helped me the most was volunteering at a free clinic weekly. My husband is a Chiropractor and I learned a lot from him. I didn’t get any derm or psych experience, which would be very helpful. Oh, more business training would help, too! NPs can open their own practice and work independently (in some states), but not many know how to run a business.
    For NPs, I think it’s all individual, and how you can connect with the right people to get the experience you want most. In the end, I feel pretty well prepared to stumble through the first few years without hurting anyone! In a few months, I believe I will be ready to take on some NP students!
    PAs, on the other hand, always have physicians at their side. Maybe more formal medical training?

  • Katie Gerlach, ACNP says:

    AGREE! I felt a lot of valuable time was wasted on classes like Nursing Theory. And despite the time we have spent at bedside, clinical experience that involves planning diagnostics and treatment is very different from clinical nursing experience.

  • Lynn McComas, MSN, ANP-C says:

    I agree with this article. I do not discount the years of experience that we have as an RN before becoming an NP, but we are doing our profession a disservice by NOT training more on procedures and things we use regularly in practice. Plus allowing NP students to train in a variety of clinical settings and not just the standard (for example: Family Practice; Peds; OB/Gyn) it will help ease the Preceptor problem for NP students.

  • I have been a nurse for 35 years. When I went back to school for my advanced degree I was looking forward to learning the skills that I had seen other NPs perform. When I graduated this past December I felt so unprepared. I got a prn position in urgent care, my background is in emergency care. I was in tears by the end of the 1st day. Another thing I think NP programs fail to do is help the experience nurse make the transition from an RN to an NP. I do not think that a nurse should be accepted into a NP program with no nursing experience. I spent a small fortune to further my education, I’m applying to a fellowship program in order to learn what I should have been taught.

  • Reading these comments makes me wonder if FNP’s know what their training was intended for and how the NP education differs from the PA’s. NP’s have so many opportunities if they work in their scope of practice (depending on the state, and legislative changes occurring daily).
    Basically:
    All NP’s (As of 2000), have a BSN in nursing which included a core of heavy sciences (A&P, Micro, Chemistry, Biology, and heavy liberal arts). Every BSN course is taught using a nursing model and “Evidence base practice for theory.” All BSN programs must include specific courses, with a heavy science base such as: Pathophysiology, pharmacology, health assessment in addition to always teaching and reviewing patho, pharmacology, health assessment with course taught (through the lifespan). Nutrition (healthy and patho), communication skills, how to safely administer medication, change dressings, inserting and maintaing care for IV’s, legal charting, the nursing process, triage, and how to intervene as a patient’s advocate is also a big part of the program. The BSN nurse also learns how to continuous assess their patients for positive and negative changes and make life changing decisions when when patients are under their care. The RN graduate is a generalist and has the skills to administers, supervises, manage and can even research needed additional diagnosis and interventions, of patients when under their care. The BSN-RN is the person in the middle of the health care team and manages all care of their patient from a variety of health care providers (MD’s, NP’s, Pharmacist, Respiratory Therapist, radiology tech, Physical therapist, family of the patient, and I could go on and on).
    Students who attended BSN Programs, also have clinical hours every semester in their junior and senior year (4/5 semesters). The rotations required must include but are not limited to: Nursing home or geriatrics, pediatrics, patients through the life span, surgery, pediatrics, PICU, ICU, CCU, ED, home health, Medical-surgical, psych (Normal and abnormal), L/D/R/P and GYN with an emphasis on women’s health and a clinical preceptorship. MD’s get their independent skills post residency, NP’s perfect primary care skills working as a RN. I would advocate that BSN graduates have a minimum of five to ten years prior to entrance into a NP Program. While the duties differ than the RN, the experience obtained working as a RN, is extremely beneficial to the NP upon graduation.
    The FNP’s education is not the same as the PA. FNP’s are educated and prepared to work in primary care medicine, not emergent care areas such as any ED, ICU, PICU, NICU, CCU etc. In fact, NP’s who are doing so are working outside their scope of practice (Wonder why the MD signs all your charts). I look for Boards of Nursing (BON) to start requiring NP’s who are working in areas outside their training and scope of practice, to soon require a Post Masters Certification track for a NP acute care certified (In their area). These tracks are four semesters with clinical (24-Post-Master hours).
    The purpose of the FNP program, is to educate and prepare their graduates to care for the family in a primary care office not an emergent care facility. While acute care also falls in the NP’s scope of practice, their is no follow up for patients seen generally since most patients have acute care illnesses, (colds, flu, sinus infections, etc).
    The Physician Assistant (PA) education, consist of a Bachelors degree with a focus very different than the NP. PA’s may have a degree in any undergraduate major (Most programs prefer science backgrounds, but not required). Once accepted into a PA program, the student completes a 12-month classroom content, similar to what the MD completes in four-years. They then spend the next 12-months completing clinical rotations similar to what the MD does in three-years. PA’s learn from the medical model. Their scope of practice is mandated from the medical composite board of their state. PA’s educational focus is to work with any physicians in any speciality. Their practice (every state) is a supervised practice.
    NP’s work under the nursing model, and depending on what state they live in, will determine the autonomy of their practice. There are 19-states where the FNP has a total autonomous practice in primary care (Lifespan). The other states, NP’s work under two different agreements. The first agreement of NP practice, NP’s work under a nursing model and their BON regulates their scope of practice. This practice requires a delegating or supervising physician for the NP to prescribe medications and some parts of their practice is supervised. For example, signing death certificates, ordering physical therapy and CT scans. These exceptions may vary per state. Lastly, NP’s work in states where their practice is totally supervised by a physician. This practice is identical to the PA’s practice in every state.

    Much is changing and daily for NP’s advancement in primary care. One reason is due to tremendous need for patients who still do not have health care (can’t afford Obama care) or do not have a doctor available. AANP supports the AANP consensus model for APRN’ which endorsees independent practice for NP’s who work in primary care.
    The next time a NP questions their training and education and ask their-self, was my NP education insufficient or inadequate compared to the PA? I would encourage each to ask, “Am I working in an area where my NP degree educated and prepared me to work” ? If working in any emergent care unit, then the NP is working outside their scope of practice and training. This may explain the frustration, lack of acute care skills required in an acute care setting, that were not taught in their primary FNP Program.
    One last thought, The NP who doesn’t know how to complete an orthro assessment, there are U-tube videos that would explain and show how a good assessment can be done. I hope this information is helpful to understand why so many NP’s are confused and feel inadequate in their current role. I had to complete basic research to understand the information!!! We NP’s need to do a better job educating each other, MD’s, PA’s etc exactly what our role is and how our scope of practice and education is different than a PA . Best to all and to our wonderful profession!! Jo K.

  • Every single one of my classmates expressed the same sentiments about the focus on theory during our acute care program. The format for nurse practitioner education must change. Patients are getting sicker and their care is getting more complicated. To much focus is being placed on paper writing at the expense of clinical education. Knowing how to write a 30 page paper is not going to help me with a critically ill patient. Nursing theory is no substitute for clinical knowledge. I sincerely hope the “powers that be” take heed and listen to the concerns of their students & graduates. Nursing education is beyond due for change.

  • I feel that NP programs should be more lax in the clinical area. They do not (even the online courses) serve working nurses very well. It is almost impossible to work a full time job (M-F) and do this school. Why don’t they allow urgent care clinicals? It makes no since to me. I’ve been a nurse for 20 yrs. I know how to assess pts and read charts. I just need to know a little more on medicine/dx and diagnostic readings.

  • I agree with JoK. A FNP gets frustrated with their ‘lack of clinical skills’ needed for acute care patients because THEY ARE PRACTICING OUTSIDE OF THEIR SCOPE OF PRACTICE. FNPs are educated and trained for primary and preventive care in well-clinics. They do not receive clinical hours in the acute setting. Acute Care NPs, on the other hand, are specifically educated, trained and receive 550 clinical hours all at the acute level. We cannot treat well patients. You cannot treat acute patients. Read your SOP carefully. You are treading on thin ice to treat patients in the Emergency room or admitted. You cannot order IV fluids. You cannot perform invasive procedures. These are skills the ACNPs went to school for. If FNPs want to work in the hospital, you need a post-masters ACNP. If an ACNP wants to provide care in the well setting, they need a post-masters in either FNP or ANP. This is just the way it is. You cannot just go to a seminar and learn to insert a chest tube, or perform an epidural. Also, Just because a FNP may have been an ER RN in her previous life, absolutely does NOT qualify her to work as a FNP in the ER. Read your scope of practice , people.

  • What a lot of people don’t realize is that this random number of 2,000 clinical hours for PA programs does not equate to actual clerkship/clinical hours that are completed in the program. Many programs have only 500-600 hours for actual clerkship/clinical time similar to the NP programs.
    A lot of programs are pulling in the time they like to see applicants have volunteered, and or worked in some avenue of the health care industry from a scribe to a lab tech, to an EMT & so on & so on. These additional hours that are roped into the claim of 2000 clinical hours are not always upheld for acceptance into the program either. In addition, some don’t even require a BS, and accept a BA.
    As NP’s we carry the minimum of a BS, and our clinical as an RN before entering a NP program, with most carrying years of experience as a RN. If a PA program can count hours as a scribe towards their clerkship hours, how can an RN’s experience not count?

  • DEITRA GATES DNP ACNS-BC says:

    I think the main problem is the rigidity with the programs. Many NP programs will not allow the students to be percepted by an MD. That is a huge mistake and it makes the learning curve steeper. If the NP schools want to be smart, let MDs precept the NP students. They will still be NPs, but trained like PAs and more solid for clinical practice.

  • Gabrielle Haynes says:

    I agree…I am wanting to return to ER as an FNP and see many obstacles. There are plenty of paid residencies for MDs but where are the NP Fellowships? Few slots nationwide in any area of practice. My hope is not to serve in high volume ERs–been there, done that as an RN—but to serve rural, needy communities where no doctor wants to go. I see liability as another big obstacle–without some further training how would that play out in court? Those papers were a waste and so doing a post masters certificate seems like a waste of time and money!

  • NP programs need to return to the previous prerequisites for admission:
    2-3 years of clinical RN experience and
    demonstrated assessment expertise
    If a NP program will not allow a student to be mentored and taught by a MD or DO, then the prospective NP should find another program.

    And a further thought — NP students should be allowed to study 1-3 business course so they will be somewhat prepared to open their NP owned practice.

  • Colleen,
    I agree with what you said about making sure we stay in our scope of practice, but if you think we only see “well” patients in primary care you are mistaken. Patients sometimes show up in my office clearly having needed to go to the ER and I often have to think much more critically than you might think, even when they don’t need to go to the ER. I very much agree with many that we do not get as much clinical training as we should. I would have loved more time with clinical and less time with papers. Thankfully I am with doctors who treat me like I’m an intern and that is a tremendous help to me! I did meet PAs during my clinicals who were getting certain rotations that I did not and was always jealous.

  • Quite a few posts assume PAs go into school with limited experience and therefore need those 2000 hrs of clinical rotations. That’s not very accurate. My program has a “minimum of 2000 hrs” patient experience, that’s just a threshold to weed out applicants. My class average patient care experience is 10,000 hrs. These are not hrs as a scribe. My class has 4 nurses a few paramedics, a few Emts and a lot of combat medics. Far from limited patient care experience.

  • Kitt Richards says:

    I agree with this article. I am a PA and have worked with NPs in clinical settings which require procedures and radiologic interpretation. I was very surprised by how, for instance, an NP in one setting did not know how to read an xray, or how alien (and therefore daunting) performing (and becoming independent with performing) procedures was to them. I think NPs would be far more confident and comfortable – especially in acute care or surgical settings – if they had the kind of training we did.

  • I am a PA and I have precepted both a PA and NP student. I agree with the post and I can tell you that there is a visible/tangible difference in their preparedness in clinic. Besides the lack of procedural and diagnostic interpretive skills, I noticed a difference when I would “pimp” the students. I had to teach my NP student basic Pathophysiology because they couldn’t explain the pathophysiology of the common diseases in Primary Care and told me they never learned it to the extent I expected. The PA student knew most of the time because these were drilled in us. Also PK and pharmacology was another weak area for the NP student and some of my NP colleagues for that matter. I do envy the NP lobby power though, so you got that going for you.

  • Linda Stone says:

    My personal thoughts on 3 things NP programs need: 1. Focus on procedure skills and diagnostics verses theory didactics. My entry into practice was associates degree with lots of didactic and lots of clinical , ten years later my BSN focused on a LOT of theory and didactic and scarcely any clinical that I recall. Then 10 yrs after that my MSN program pretty much followed the BSN didactics, very repetitious info with lots of busy work, providing the instructors with something to critique and grade, little hands on except when we were called on to demonstrate how to estabish rapport and interview a client! Post-masters FNPcertificate about 10 yrs later had an unbelievably high level of didactic verses hands on learning and practice. Again we were called on to demonstrate how we approach and interview clients verses real-time guidance in procedures and diagnostics.

    Most of my actual hands on learning/practice took place after graduation. My personal experience is perhaps a great argument for the quick implementation of post graduate 6-12 month internships where new NPs are given the room to learn by doing with an attentive, kind, and competent practicing NP, MD, or DO in your chosen area of interest.
    2. More clinical hours. Hands on time always builds skill and confidence in ability to handle situations. 3. Program data transparency. If the program rejects or demeans your request for more information perhaps you need to find another program! LSS

    Finally as a side note, who coined the phrase ‘mid-level’? Who benefits from the mid-level designation? What does that phrase convey in the healthcare arena to our clients; to potential employers; to MD/DO colleagues; to ancillary services personnel; to third party payers including CMS! Follow the money people this isn’t rocket science!

  • I’m seeing a lot of incorrect information in the comments here so please allow me to address a few of the misunderstandings about PAs. “One of the reasons PA programs require so many clinical hours is because many of them have never even touched a patient.” This is simply not true. Almost every PA program requires hands on experience before even applying. For most schools the bare minimum is 1,000 hours, with a national average of more than 3,000 hours for admitted students according to the AAPA. There are *very* few schools that do not require experience, and the few that don’t explicitly require it still typically admit students with at least some experience. “PA programs admit students with BA degrees so their standards are lower.” Many PAs come from other backgrounds besides healthcare (myself included) which often means they may have a degree in a field other than the sciences. This does NOT mean that they can enter these programs with no understanding of the hard sciences. Students must complete and do well in advanced coursework in Anatomy, Physiology, Biology, Chemistry, Microbiology and Statistics at a minimum. Many programs have further requirements with coursework in Genetics, Physics, Organic Chem, Biochem, and other upper level bio courses. “You don’t even have to have a bachelors to be a PA, you can do it at a community college.” While this may have been true at one time, it is no longer the case. Most PA programs are masters level and the few that aren’t must convert to master’s level by 2020 to keep their accreditation. The PA profession is still relatively young, having just celebrated it’s 50th anniversary this year. It has been through many changes and growing pains during that time, and will continue to do so for the forseeable future. For further information about PA education check out this briefing from AAPA: https://www.aapa.org/wp-content/uploads/2016/12/Issue_Brief_PA_Education.pdf

  • The three reasons are exactly why, as an RN ready to further my education, I chose to go to a PA program, rather than an NP program. My RN program (BSN) was heavy on the theory. We were told we would be the ‘nursing leaders’ – so that when I graduated from RN training, I didn’t know how to do bedside nursing very well. Sure, I learned, but I was behind the curve for awhile. I did not want the same thing to happen when I returned to get my ‘clinician training’ – I looked at NP programs, which, at the time, were Masters programs, and the students I saw coming out did not know how to practice.
    It so happened, at the time, by attending the Primary Care Associate Program at Stanford University, I was able to get both my PA and NP certificates – this is no longer possible.

  • I agree, I’d add that the “lunch and learns” should be shared amongst MD, PA and NP students, my school had the NPs in a building clear across campus from the MD/PAs so there was no sharing of lectures. I feel at a pretty large disadvantage and am on a slow learning curve looking up things in practice that I feel I should have been taught, then drilled into me. But for instance we never received a proper lecture on diabetes. It was a group presentation/ project. That was it.
    I had a great ED job but unfortunately, I just wasn’t exactly ready, so am happy now with a private practice and a MD who will help me when I ask. –NP

  • I agree, I’d add that the “lunch and learns” should be shared amongst MD, PA and NP students, my school had the NPs in a building clear across campus from the MD/PAs so there was no sharing of lectures. I feel at a pretty large disadvantage and am on a slow learning curve looking up things in practice that I feel I should have been taught, then drilled into me. But for instance we never received a proper lecture on diabetes. It was a group presentation/ project. That was it.
    I had a great ED job but unfortunately, I just wasn’t exactly ready, so am happy now with a private practice and a MD who will help me when I ask. –NP

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