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The Road To Becoming A Nurse Practitionerby Pat
Sonnenstuhl BSN, CNM, ARNP, RH |
 |
Things are very different today than they were when I was in high
school in 1965. There are so many career options in the health field now for women that don't require years and
years of education. I am initiating a 4 part article about the road to becoming a nurse practitioner (NP). It will
also provide you with things to think about if you are interested in any aspect of the health care field. A nurse
practitioner is a Registered Nurse (RN) with advanced training as a nurse practitioner. The current recommendations
in many states is to become an advanced practice nurse (APN) - usually a 4 year Bachelor of Science (BS) in Nursing
degree, and a two year Master of Science (MS) degree in the specialty field. So, this becomes a minimum of a 6
year educational journey. If you are in high school, and think this might be a direction in which you want to go,
hopefully this article will be helpful for you. If you are already out of high school, and are thinking about this
career, this article will provide you with further direction.
I. Decision Making and High School Choices
For me, from somewhere in my early teens I wanted to be a nurse. In high school I started looking at nursing programs
and was trying to choose between a four year program and a two year program. Nursing has gone through some evolutionary
phases, and initially there were three year programs affiliated with hospitals, and four year or five year university
based programs. The development of the community college in the early 1960's allowed for nursing to move into an
affordable educational institution, and today there are several ways to become a nurse. Some initial questions
to ponder:
- What do you want to do?
- What do you like to do?
- What are your interests?
- What are your talents and strengths?
- Where are your weaknesses? Can you strengthen them?
- What will you need to study
- How do you feel about the sciences?
High school is a wonderful time for taking stock of your talents, skills and interests and look at what seems interesting
to you. Nursing will require a good understanding of the sciences and people, so taking science courses and psychology
will help you to prepare yourself. The basic biology and chemistry classes are essential, along with anatomy and
physiology. I also think learning to write and communicate are very important, and these subjects will help build
a good foundation for you. Nursing requires a broad range of skills: both decision making and dexterity skills.
Getting into a nursing program would not be difficult if you have a good foundation in these areas. Of course,
being involved with leadership programs also helps to broaden you and gives you additional confidence.
When I was in high school, I wanted to be a nurse, and volunteered my time as a candy striper at a local hospital.
This exposed me to nursing, and to other health fields such as physical therapy and occupational therapy. There
are many other potential careers in the health field, that might require less education. Examples include ultrasonographer,
phlebotomist or physician's assistant. Visiting a local hospital, or job fairs are always ways to get exposed to
different health careers. All of these careers require the basic sciences, but in differing degrees.
In the 1960's, the field of "advanced practice" nursing and midwifery were in their infancy. Now there
are many paths and ways to reach this goal, and also many more regulations and guidelines. At one point you could
be an RN and take one year of training and be a nurse practitioner. Today the trend is towards having a BS in Nursing
and then two more years at a Master's Level. The programs include more of an expanded theoretical framework and
research component. There are many aspects of advance practice, such as a woman's health nurse practitioner, pediatric
nurse practitioner, nurse anesthetist, nurse midwives, clinical nurse specialists and surgical assistants. All
of these have nursing as their basis and core. The particular focus of a particular program provides the framework
for advanced practice.
The profession of Nurse Midwives is over 70 years old and is probably one of the oldest advanced practice nursing
professions in the United States. Originally you could have a two year RN degree and receive a midwifery certificate
in one year. A Bachelor's degree and a Master's Degree weren't required. In the 1990's, minimum entry is a Bachelor's
Degree in Nursing. This is partly to meet the requirements of individual states, and partly to emphasize that a
nurse practitioner's role is advanced practice. I am one of those individuals caught in this transition period.
I started out with a basic two year RN program in 1965. In 1980-81 I entered a Certificate Midwifery program, without
a Bachelor's Degree. In 1983 I did obtain my Bachelor's Degree in Nursing, as several western states were requiring
this for advanced practice. In 1962 when I was a senior in high school, I had no idea where this career tract would
take me. I simply wanted to be an RN.
II. The Basic Nursing Program
LPN PROGRAMS (1 YEAR)
RN PROGRAMS (2 or 4 YEARS)
There are many opportunities for you to get into the health field. You can start as a nurse's aid and then move
into the licensed practical nurse program (LPN), and then into an RN program. In many states at local community
colleges, there are one year LPN programs which transition into two year RN programs. This first year provides
you with the foundation to be an LPN, and you take the exam at the end of your first year. These programs provide
you with basic assessment skills, an understanding of pharmacology and basic patient care within a variety of settings.
You are equipped to work within a hospital, or within a health care provider's medical office. The second year
expands upon this basic learning, providing more experiences with complications and the development of more advanced
skills. At the end of the second year, you take the RN degree exam, and then work as an RN. The advantage of this
tract is you can work along the way and earn an income. For some this is a necessary way to go. Sometimes students
have family obligations to consider, or the fact that they might be moving and just want to complete one piece
of their education. Community Colleges are inexpensive programs, and many have grants and scholarships available.
Some individuals might want to gain their education over a longer time frame. Sometimes students take their sciences
before entering the basic LPN or RN program, and this then makes this a two to three year commitment. Contact your
local community college to familiarize yourself with their requirements and the courses they offer.
Another route is a 4 year RN program. For all RN programs, you need specific sciences such as chemistry and anatomy
and physiology, and many times this becomes a three year process as a minimum. A 4 year program includes all of
the sciences. Some feel the 4 year programs provide more of a theoretical framework for practice, more time in
the classroom and less time with clinical experience. This is a more concentrated course of study, and the program
probably moves at a bit of a faster pace.
More and more states now require you to have a BS in Nursing to become a nurse practitioner. You can still start
out with the LPN-->RN and then do a bridge up program and get a BSN, so the majority of your education might
be within your local community. This was my experience. I started my nursing career with a two year RN degree from
a local community college. Years later I took a bridge up program, and by taking specific theory classes was able
to obtain my BS in Nursing. It seems I do things in steps, and this has provided me with rich experiences all along
the way. I worked a few years an RN, and built my skills as a nurse. I have always been able to work and use my
skills as a nurse. After graduating from my basic RN program I worked at a hospital and was able to earn a living
and gain work and life experiences. Further education had more of a focus.
If you already are an LPN or RN, look around your community for a BS in nursing program that will give you credit
for what you already have. There are some excellent community based programs linked to Universities. If it has
been a long time since you were in school, you might need to repeat specific courses, or take an exam to prove
the knowledge you have. If you are in high school, begin to plot out how you can best accomplish you goals. If
you need to work for awhile, perhaps a two year program will meet your needs. If you have the motivation to enter
a 4 year program that is the way to go for you. What matters most is for you to find the program that best meets
your needs.
At the completion of your program you take the same examination for each degree. For example, when you complete
the LPN program, you take the LPN exam. When you complete the RN program, whether a two year or four year program,
you still take the same RN exam. This supports the thought that the two year RN program and the four year program
are basically the same, one providing more theoretical framework.
The courses in nursing range form learning basic nursing skills, giving shots and medications, taking histories,
doing baths, vital signs and learning assessment skills. There are lots of specific clinical skills you learn in
a nursing program, plus leadership skills. Because there are so many aspects of nursing, the programs teach the
basics of how to care for patients. You learn properties of medications and how to administer them. After the basic
skills courses you will take specific courses in specific areas: medical,
surgical, pediatrics, obstetrics and sometimes specific specialty
areas such as short stay, long term care and emergency room. Along the way you are introduced to various nursing roles, such as staff nurse,
office nurse and ob nurse. In all RN programs the content is the same, as the RN exam is the same. Once you have
your RN degree, everything else you do builds upon that. In BSN programs there is more of a focus on theoretical
frameworks and the broad concepts that help determine care. Some programs have more of a public health focus, others
a medical model focus.
There are also a few programs that don't fit this model. For example, if you have a degree in something else and
decide you want to be a nurse midwife, Yale has a three year program. At the end you have a Masters in Nursing
and a Nurse Midwifery degree. One to two years are spent teaching nursing as a foundation.
III. The Nurse Practitioner Program
Nurse practitioner programs are now almost all at the Master's Level. This is because they are considered "Advanced
Practice" over and above a basic BS in Nursing. This has not always been the case, the trend is in this direction.
At one time there were many nurse practitioner programs that were one year courses. The course was a very didactic
program with courses in management of health problems.
Nurse practitioner programs have a health focus, with learning assessment skills, problem solving, teaching and
management. You are taught normal and deviations from normal, and learn many of the routine functions that once
were traditionally things only physicians do. The courses taught are basic assessment skills, management and problem
solving, pharmacology, and then the actual clinical practice. In the clinical practice component, you usually work
with another nurse practitioner and just learn and develop your basic skills. You learn how to take histories,
do exams and provide teaching and follow up.
Whichever field you choose will have its own set of skills. There are a wide variety of nurse practitioner programs,
and some are quite specialized, such as a mental health nurse practitioner, or nurse anesthetist. When looking
into these programs look carefully at what your interests are and where your talents lie, and also how flexible
you are about where you can work. A family nurse practitioner might have more job opportunities, especially in
a rural area. A nurse anesthetist might have to move somewhere else to be able to use her skills. If you work with
adults, you will learn all about adult health. If your focus is children, you will learn about children. Nurse
practitioners learn to recognize normal from abnormal, and learn how to help people improve their own care. Consultation
and referral are a basic part of the programs, and learning one's own limits, as well as the ability to prescribe.
These are some of the reasons that nurse practitioner programs have been moved to the master's level; so much is
required for learning, and it is truly over and above basic nursing skills.
As a women's health care nurse practitioner/certified nurse midwife, I learn about family planning and women's
health care in addition to courses on prenatal care, postpartum care and of course learning about deliveries and
how to assist birthing babies. I love women and helping women make positive decisions about their health. I perform
routine annual exams including pap smears and physical exams. I'm not particularly interested in caring for children,
nor for men. If I were, a better direction would be family nurse practitioner.
Midwifery programs have changed through the years. In 1980 I went to Mississippi to a Certificate program of one
year duration. My family stayed home in California. A program called Community Based Nurse Midwifery Program (CNEP)
developed out of the Frontier Nursing Service. This provided individuals with an interest in midwifery do learn
their course work at a distance, but do their clinical experience in their local
community. This has become a
very popular option in addition to the two year midwifery programs and there are now several midwifery and nurse
practitioner programs that are considered Distance Learning Programs. This provides a wide and rich source of education
for individuals following these paths. For more information, visit Innovative Midwifery Educational Programs.
The masters component adds a year of research classes, specific clinical focus, and some nurse practitioners actually
do a major research project. The trend now seems to be towards a manuscript or clinical practice guidelines rather
than a time consuming research project. Many states require the Master Degree to be in Nursing, however this is
being challenged as new programs develop and produce qualified nurse practitioners. I attended a one year Certificate
program in 1980-1981, which provided me with the clinical skills to be a Certified Nurse Midwife. I didn't have
a BSN at the time, and this met my needs. The courses I took were the same I would have taken for a MS in Nursing,
minus the research courses. Following this program I went on to get my BS in Nursing, as I could see the trend
in the 1980's was heading towards requiring a BS in Nursing for any advanced practice. In Oregon and Washington
a BS in Nursing and a MS in Nursing are required for advanced practice. This spring I embarked upon a new phase
of my education. I am in a masters completion program through the Institute of Midwifery, Women and Health through Philadelphia University. This gives me credit for my certificate
in Nurse Midwifery and adds the research component to a masters degree. I can choose my own research project, and
will be researching Insulin Resistance and develop Clinical Practice Guidelines to help practitioners work with
obese women. the program is a year in length, and totally a distance learning program, meaning everything is done
by computer. It is thrilling to meet and discuss issues with midwives from across the United States. When I finish
my degree in May of 2000, I will have a Master of Science with a focus in Midwifery. There are several other programs
that are distance learning formats, including basic midwifery programs and masters completion programs. Be sure
to check the listed links for more information.
The American College
of Nurse Midwives (ACNM) , the umbrella organization for Certified
Nurse Midwives and Certified Midwives, is almost 45 years old as an organization in the US. Midwives were mentioned
in the bible, and have been around from the day women first gave birth. Someone had to help her and midwives means
'with women'. There are also non-ACNM midwifes called Licensed Midwives or Certified Professional Midwives. These
practitioners usually do not have nursing as a basis for practice, but rather teach midwifery and the skills required
to be a midwife. These individuals usually assist with home births, usually can't prescribe, nor obtain hospital
privileges. For more information about non-nurse midwifery, you can check out the
MANA web
site If you want more information about the field of midwifery specifically, visit
About Midwives
and do more research.
The American College of Nurse-Midwives was founded in 1955 to provide research, accredited education programs,
establish clinical practice standards, create liaisons with interdisciplinary health care professionals, state
and federal agencies and members of Congress, and develop a productive infrastructure. The mission of the ACNM
is to develop and support the profession of nurse-midwifery in order to promote the health and well-being of women
and infants within their families and communities. The philosophy inherent in the profession states that nurse-midwives
believe every individual has the right to safe, satisfying health care which respects human dignity and cultural
variations.
IV. Out In The Workplace
What life is like once you finish your basic nurse practitioner education will depend a lot on where you live and
what you want to do. If you start with a basic RN program, working a few years in basic nursing really helps to
polish off your skills and give you a good foundation for future study. Learning assessment skills will this experience
will provide you with assessment skills and an understanding of life processes and people.
In some communities there are plenty of jobs for nurse practitioners. Sometime where you do you clinical experiences
will have a job waiting for you. In other places you will need to apply for a job and carve out your own niche
Some nurse practitioners are in independent practice, some work for physicians, and some work within Health Maintenance
Organizations. A good example is Group Health of Puget Sound. They have employed "midlevel providers"
for over 10 years, and are utilized for the specific abilities they have. I know other NPs who are employed by
a specific organization and work in rural areas in rural clinics. Some nurse midwives are employed by a specific
hospital, and some nurse midwives are employed by physicians. Others practice independently, as their state allows.
This means they can practice without being in the same office as a physician.
Individuals looking at health trends seem to be of two opposing viewpoints: Some are concerned there are too many
nurse practitioners and not enough jobs, especially for either the new graduate or the very experienced nurse practitioner.
The Center for the Health Professions University of California,
San Francisco is researching the field of providing health care, and has recently published several excellent papers
supporting the use of nurse practitioners and nurse midwives. Many
feel the use of nurse practitioners can lower health costs, as nurse practitioners perform many of the basic and
routine exams, allowing physicians to practice their specialties. A key factor is how nurse practitioners are reimbursed:
Medicare and Medicaid in many states do reimburse nurse practitioners. In settings where the nurse practitioners
are employed by physicians, they usually receive a salary, sometimes a bonus, and their malpractice insurance is
usually paid for by their provider. In other settings, nurse practitioners might be excluded from practice by specific
insurance plans because they are not physicians. This limits the consumers choice to physicians, when they might
want to see a nurse practitioner or nurse midwife for their care. In the state of Washington, a recent bill is
to take effect soon. It is the "every category of provider" bill which mandates insurance companies offer
nurse practitioners (along with other categories of licensed providers) within their plans. The recent PEW Report:
Charting a Course for the 21st Century: The Future of Midwifery is a very interesting document, and can be found at:
http://futurehealth.ucsf.edu./
I have been a nurse midwife for almost 20 years, and am thrilled I have found a career that is still exciting and
interesting to me. I have provided birthing assistance in homes, hospitals and birthing centers, and provided health
care to teens, and women of all ages, including seniors. I provide prenatal care, family planning services, and
routine women's health care, along with gyn services. I have worked with a variety of populations, including Hispanic
women and Native Americans. I appreciate the richness of my experiences.
I like being a nurse practitioner, as I like the preventative focus I can provide. I feel with education and motivation,
women can become healthier and grow healthy babies. Once someone is within the hospital they need to get well before
they can focus on staying healthy. Nurse practitioners try to identify problems early and prevent hospitalizations.
The fields require a variety of skills and talents. There are lots of job opportunities along the way. As a midwife,
I consider myself an expert in normal, and keeping women and babies normal. I have a very strong preventative health
focus. I know my limits and when to consult or collaborate with a physician or other health care provider.
Working as a NP, you learn that all working in the health care field are interdependent. No one person is able
to work solo, all work together. No one person knows everything, and each individual has someone else to refer
to who might have more knowledge. For example, as a midwife, I feel I know and understand normal, and recognize
deviations from normal. I might confer with a physician, whether a family practice physician, or an Obgyn. Next
in line would be a perinatologist, or expert in pregnancy. Each one along the way gets further education to make
them a specialist in their field. An Obgyn might be well trained in surgery and complications, but have less training
in normal nutrition and normal birth. I have been associated with the health field for over 30 years, and have
a wide variety of skills and knowledge about health and health care systems.
Most states that license nurse practitioners have requirements for continuing education and/or continuing competency.
This usually requires a specific number of continuing education courses, pharmacy courses, and sometimes a requirement
to perform a specific number of hours within a two year period of time. The purpose of this is to keep the nurse
practitioner current in her field. This can be fun, as you choose courses you enjoy, and do not need to get a grade
or write a paper for the course. In states where nurse practitioners prescribe, they need continuing education
to maintain their ability to prescribe. Again, they choose courses they are interested in, and this is not a difficult
thing to do.
The basic course to becoming a nurse practitioner is about 6 years. By doing it in pieces you are able to expand
your knowledge base and understanding of what you are doing. Physicians usually take their courses in sequence,
each one following the others. I think the flexibility nursing provides, allows for greater individuality, and
the selection of a direction you have the most interest in. Hopefully this has helped you to look at some new career
options and opportunities. You can learn more about these fields by doing a web search. Other things you can do
are: Follow a nurse around for a day. This can be either within the hospital or within a providers office. Visit
a health providers office and follow a nurse practitioner around for a day If you are interested in a specific
field, try to find someone in that field who can help you make decisions and who can answer questions for you.
Write reports about these topics and see where your studies lead you.
Once you've been in the field, there are lots of options for use of your education:
- Independent practice
- Working for an agency (PPH, hospitals, health departments)
- Working with a physician
- Where to do what you want to do
- Home birth
- Hospital or birth center birth
- Clinic
- Office
V. Where Your Education Can Take You
- Educate other students: Some NPs go on to educate either LPNs, RNs or other NPs within a formal educational framework
- Write curriculum: for NP programs, journals, or most recently, for On Line Continuing Education
- Write Text books for use in Educational programs
- Branches from your original goals: consultation work, writing for others, working for agencies such as health departments, state or federal agencies.
- Foreign travel and working oversees
Some good web sites to visit that will provide you with more information:
- A Career in Nurse midwifery
- Innovative Midwifery Educational Programs
- Midwifery Education
- Nurse Practitioner Central
- Job Vault
- Research the Health Care Industry
- Nurses
- MANA
- About Midwives
The author invites you to submit
questions on careers in the Nursing Field for follow-up articles.
©Pat Sonnenstuhl, ARNP, CNM. May, 1999 Young Women at Obgyn.net
Web Midwife: www.cnm.wa.org
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