In Support of Independent NP Practice

[Corey Narry]

Resources from Bridging the Provider Gap:

From the National Governors Association: http://www.nga.org/cms/home/news-room/news-releases/page_2012/col2-content/nurse-practitioners-have-potenti.html

- looks like state governors are in favor of practice independence for NP's

AANP Map of Practice Environments Across States, 2013

Citizens Advocacy Center: Reforming Scope of Practice, A White Paper

[BostonFNP, APRN]

I find it amusing that some of people who claim NPs are indistinguishable from physicians are the same people who poo-poo the role of LPNs and ADNs in favor of the BSN. It can't be denied there is some hypocrisy and irony there.

Does more education make one a better health care provider or doesn't it??

If one says a NP education is "good enough", doesn't it seem odd when the same person turns around and says a ADN isn't because "more education is always better."?

As to your first point, I don't think anyone has argued (in this thread at least) that NPs are indistinguishable from MDs. Our practice overlaps, but there are noticeable differences between the two (education model, scope of practice, compensation, etc). I think it would be a very hollow argument to assert that there is no difference; the studies being discussed show no difference in outcomes when the diagnosis is controlled. If you were comparing me to a orthopedic surgeon on outcomes for a total hip replacement his/her patient would likely be alive and mine would be in a lot of trouble. If you were comparing us on hypertension outcomes, at worst there would be no difference.

To your second point. In my opinion, education in your field does nothing but make you a better provider. Education matters. If I went to medical school it would make me a better provider. If I went to law school it would make me a better provider. I am constantly trying to increase my knowledge through journals, conferences, publishing, DNP classes, professional organizations, etc. I have an MSN and I am working toward my DNP. I want to get better.

Not to get off topic (just to adresses your point), but I earnestly believe that nursing should (at the very least) have three distinct levels of practice: LPN, RN, APRN. I also believe there should be three educational levels to match: ADN-LPN, BSN-RN, and DNP-APRN. So not only am I in favor of a BSN-entry for RNs, I am in favor of a doctorate-level of entry for NPs. This group includes myself.

[PMFB-RN, RN]

I also believe there should be three educational levels to match: ADN-LPN, BSN-RN, and DNP-APRN. So not only am I in favor of a BSN-entry for RNs, I am in favor of a doctorate-level of entry for NPs. This group includes myself.

*** I am curious about your opinion of the direct entry to practice (entry level RN) MSN programs? Also do you see a roll for the MSN prepared RN in (let's say) unit educator, nurse managment and similar rolls?

[BostonFNP, APRN]

*** I am curious about your opinion of the direct entry to practice (entry level RN) MSN programs? Also do you see a roll for the MSN prepared RN in (let's say) unit educator, nurse managment and similar rolls?

Personally, I think the direct-entry programs will transition from MSN programs to DNP programs. I have been involved in a consulting role in the curriculum changes for one of the well-known local programs. I all honesty, I wish there could be a much more dramatic curriculum change and I have advocated for it. I do feel that DE programs (at the MSN or DNP) levels produce adequately prepared novice NPs.

Great question about the role of a MsN. I presented a very simplified system there and perhaps I should clarify.

LPN: Associate level entry. Further bridging options to BSN and DNP.

RN: Bachelor level entry. Could be expanded to MsN in bedside, research, instruction, administration. Further bridging to DNP and PhD from BSN or MSN.

APRN: Doctorate level entry with DNP.

Academia/research: Doctorate level entry with PhD.

[Annaiya, NP]

Removing barriers to NP practice is essential. I live in a state where NPs cannot prescribe schedule 2 narcotics. One of the NPs I work with is fond of saying, "I can't treat your pain, but I can kill you..." Eluding to the fact that they routinely prescribe dangerous drugs including paralytics, but can't give a dose of morphine for post-op pain. There is no reason for this restriction other than bureaucratic red tape. Things like this hurt patient care. NPs need to be allowed by state law to practice to their full extent and need to be reimbursed at 100% for their services. Nurses in general are a conscientious bunch, who are in their roles because they want to improve the lives and health of their patients. Needless restrictions are simply that. Allowing for independent practice does not mean that NPs will all of a sudden try to work beyond their scope of practice, it simply means that can work without hinderance.

I do agree that NP education can be improved, but even in its current form, it does provide safe entry-level practitioners. I was talking to a physician this week and mentioned that I like how standardized MD education is and I'd like to see NP education get to the same point. (We were talking about how they have found NP orientation needs to be tailored to each new hire, because everyone comes in with such a variety of knowledge and skills.) Her response what that it is no different when they are training in a new MD, because although med school is standardized, the residencies are not. So they find each Fellow comes in with different levels of knowledge and skills. No system is perfect, so it's about understanding how to work with what you've got.

Pushing for independent NP practice is not about trying to make NPs into MDs. It is about removing barriers that prevent NPs from being able to do their jobs effectively and efficiently and allowing for equal compensation for equal work. To say that you are against independent practice for NPs tells me that you are very poorly informed regarding the education and scope of practice for an NP, and what independent practice really means.

[Guest343211]

I think you are the only person arguing this rather trivial point. MDs are educated in a medical model and licensed to practice medicine. NPs are educated under a nursing model and licensed to practice advanced practice nursing, a scope that overlaps significantly with the scope of medicine. To the general public, there is not much of a difference in whether someone is practicing medicine or advance practice nursing, their provider is their provider.

Show me the data to support this statement. In fact, the data shows there is no distinguishable diference between NP and MD provided care in terms of outcomes. See me previous statement, if you want to engage in a discussion that is larger than your sample size of 1, do your research.

Isn't their some irony in this statement? You are saying that the studies on NP outcomes are "qualitative" (when in fact most are not) while vehemently arguing against NP autonomy based on your anecdotal personal experience with no data to support your position. Again, lets see the "real" studies showing significant difference between NP and MD provided care.

Wow. How is her point trivial. . .at all?

Susie,

If you want to continue going back and forth with this, that's your perogative. I may be a little older than you are, and thus, I find it all to be about spinning wheels. It's a political argument garbed in very little research of substance. Anyone with half a brain can figure out that NP or DNP does not =MD or DO. The education, training, and vetting through out is different by leaps and bounds. I think the issue will become moot as more NPs realize they will be reimbursed potatoes while taking in boatloads more of patients, and while potentially setting themselves up for lawsuits, just as the MDs and DOs have had to struggle with over the years.

This is probably an offshoot of the other thread, where I refused to argue back and forth--circular stuff.

If you look, many NPs are working for hospitals--hospitalists and the like. They are not usually going into the areas where there is a major shortage of primary care providers. They are also trying to follow the money.

When you seek to help out in an area where access to care is pretty much nonexistent, God bless you. But realize in working incredibly hard in your effort to serve, you would be glad to have physicians, NPs, whoever to help you to support you in your effort to help the people in the particular area. This was the basis for the movement toward independent practice, at least from political angles. And most aren't going into these areas of to serve/practice.

So, Susie, I fail to see where arguing back and forth is worthwhile here. This is a nursing site. It seems obvious to me that you will be David going after Goliath, only "David's" hands might end up being tied down.

In terms of clinical practice and approaches, I have addressed that in the other thread. I am confident in my position because of > 20 years clinical practice in very dymanic settings for critical care and acute care. I have also walked down this road with both parents, several times, my children, my in-laws, parish nursing, you name it. IMHO, those that really were sharp as advance practice nurses had many years of strong acute or critical care experience prior to school for advanced practice. . .and interestingly, they had also developed the humility, wisdom, and just plain good sense to utilize those with more education, experience, and insight (physicians) when necessary. A wise person knows there limits, period.

I support what you are saying Susie, but you will be spinning your wheels. For me, I would allow the opinions the last word and let them run their course.

So much of this seems to be about validation, and it's silly. We are validated by internal things that are way more substantial. NP in whatever can be validated by examination and other measures. MD in whatever can be validated by their measures, which really are incredibly demanding in comparison. These paths can lead to some form of legal validation in order for a person to practice within certain parameters. It has nothing to do with validating the individual, whether it is as a person or in terms of excellence of practice in the particular area.

Listen, no one says that NPs shouldn't have the right to order home health care without sign-off from a physician. That's ridiculous, b/c the determination of such falls directly within nursing practice's domain. The whole assessment for that is pretty much nursing based. It gets tricky, however, when you start pushing the boundaries out further and further as nursing functions in something that falls specifically within medicine's domain. And this is where a big part of the argument gets stuck. What is within who's domain? That's a shame, because, like it or not, prescribing medicine is foundationally under medicine's domain, period. Yes there have been changes, but again, such changes were exceptions made in order to help get some kind of primary care out into the remote areas--where no one, neither physicians nor NPs nor PAs wanted/want to go.

In terms of compensation, well this for all health practitioners will invariably have to be cut, while mandating that more folks be accomodated into practices. It is becoming and less and less a financially promising proposition to enter into primary practice or even certain specializations--regardless. As such the test will come down to commitment to practicing and serving with less and less compensation. It's going to effect everyone in direct practice eventually.

[myelin]

I think a lot of the opposition in this thread is coming from a very idealized notion of MD and NP supervision in practice. The reality is that most MD supervision/collaboration varies widely across states to a point of absurdity (in some states it's just a piece of paper that says "I'll call you when I need you" others require chart review every few months, and it's typically an arbitrary number of months. In some states the laws are stricter).

If NPs get independent practice it isn't that they will go from having a MD watch their every move to suddenly doing whatever they want with no oversight. First of all, there isn't that much oversight to begin with in many settings and there is no evidence to show that supervision/collaboration requirements contribute to safer care. NPs (like all providers) typically collaborate with other providers and know when to refer out. Nobody practices in a vacuum. The point is that there doesn't need to be a law that forces NPs to collaborate... they already do. These regulatory laws basically make it harder for NPs to practice and for patients to receive care. That's about it.

I agree that it's really ironic that most of the opposition on here comes from a place of anecdotal data. No one has posted a study that supports the notion that NPs provide inferior care. Also, apparently every single study that's been done which has found NPs to provide equivalent (or even, gasp, superior) care, is apparently fundamentally flawed. Though posters have yet to clarify what the flaws in the studies are, other than to complain about survey data (which is used widely across fields). As someone from a research background, I'm more than happy to have a conversation about research methods and data analysis techniques, what works, what doesn't, etc. However, I suspect that the people who are complaining about the studies being flawed haven't read them AND wouldn't know where to begin when analyzing a study for flaws.

In other words, it's a tempest in a teapot. Nobody is saying that NP = MD. We want to get rid of laws that limit NP practice. These laws do not need to exist and they end up making it harder for NPs to practice and provide patient care. There was an article about a NP in Texas who wants to provide primary care to her community that is in desperate need, but there's no physician nearby to oversee her. She plans on moving to New Mexico now, where NPs have independent practice. So now her community will not have a primary care provider due to these laws.

[Guest343211]

I edited some parts that speak to what you are saying myelin.

Getting rid of laws that define the basis of practice is problematic. What falls under medicine and what falls under nursing? You see, it is not that easy.

And as I pointed out above, most advanced practice nurses do not go into the remote areas. I say let those that are going into these remotve areas provide a certificate of need to function in this way, b/c the truth is, most midlevel practitioners aren't going into these areas to serve. It's about their bottom line and lifestyle as much as it can be for physicians. But it's important to be careful in defining what falls under medicine and what falls under nursing. You can't have it both ways, saying nursing = nursing and nursing -/= medicine, and then say you want freedom to practice medicine, even though you are nursing and NOT medicine. Why should nurses cross this line, unless you can demonstrate a direct need? It's a precarious situatuion.

But no worries. I think you will get what you want; but it will be about government intervention and cutting costs. Be careful what you wish for.

[BostonFNP, APRN]

Wow. How is her point trivial. . .at all?

Trivial. Elementary. Overly simplistic. Obvious. Unimportant to the matter at hand.

[myelin]

But no worries. I think you will get what you want, but it will be about government intervention and cutting costs. Be careful what you wish for.

Heh. New Mexico has had NP independent practice for over 20 years and the world has yet to collapse in on itself. I lived in an independent practice state and knew NPs who had independent practices (even saw one for care) and they were very happy indeed. I'm not sure what you're alluding to here, but I'm quite aware of what I wish for, thanks.

[BostonFNP, APRN]

If you look, many NPs are working for hospitals--hospitalists and the like. They are not usually going into the areas where there is a major shortage of primary care providers. They are also trying to follow the money.

What's your source for that? Per the Advance2011 survey only 17% of NPs work in hospitals.

As far as salary: rural NPs make on average less than $5k per year less than urban NPs, inpatient NPs make less than $2/hr more than family practice NPs and actually make less than internal med and gerontology NPs.

[Corey Narry, MSN, RN, NP]

OP here.

Not surprisingly, this thread has taken many twists and turns that have taken away from the original intent in starting the discussion in the first place. I'm partly to blame by posting links without clarifying why I did so. I live in California, a restrictive state in terms of NP regulation, but nevertheless one among many that are in the face of an impending primary care provider shortage as the full implementation of the Affordable Care Act nears. As such I was hoping to get the discussion focused on primary care. After reading the succession of posts, many points have been brought up along the way and I would like to clarify some of the arguments made.

1. This thread is not about physicians and nurse practitioners being equal. Hardcore proponents of nurse practitioners are the first to argue that NP's belong to nursing's family of healthcare professionals and do not have the same amount of training as physicians who went to medical school. This is precisely the reason why NP's should never be regulated by a profession (Medicine) that it does not belong to nor "supervised" by an entity other than it's own.

2. Nurse practitioners ARE providing primary care in all the 50 states. Because scope of practice regulations are not uniform across the board, autonomy manifests itself in various forms depending on which state one practices and how institutional policies shape roles. Roughly thirty percent of states allow NP's to practice without a requirement in writing for a physician to supervise, collaborate, or "work under". The federal government through CMS which insures individuals under Medicare and Medicaid already calls for direct reimbursement of NP's for the services they provide. Physician presence is not a requirement per CMS regulation but ultimately, NP's are bound by their state's requirements for physician involvement if at all required.

3. NP's who own their practice (also referred to as NP business owners) are a minority. Not surprisingly, their presence can be seen even in states where independent practice is not the law. Because not all state regulations call for physician presence, these individuals are able to practice with a piece of documentation formalizing the required collaboration and periodic chart reviews.

4. NP's, by virtue of being nurses, fall under the "Most Trusted Professionals" for 11 consecutive years as of 2012. Nurses have an innate tendency to self-regulate their practice, seek to collaborate with experts, or consult other professionals. Nurses are aware of their limitations and new graduates of nurse practitioner programs are not going come in droves hanging up a sign offering independent healthcare services. We do not see that happening in states where independent practice is the law. As was already mentioned, no NP practices in isolation as every NP collaborates, consults, and seeks assistance from experts regardless of legislation.

5. Primary care is broken and fragmented in this country. Politically-driven or not, ACA is now law which raises the question of how our entire population will gain access to primary care.

6. I have never met an NP who does not advocate for leaving the choice of provider to the patient. Posters who state that they they prefer to see physicians for themselves and their families are free to continue to do so. Feelings won't get hurt and life will move on. On the flip side of that, there are individuals who prefer to see a nurse practitioner for primary care.

7. Though strong statistical data on NP demographics are lacking, the poster that says majority of NP's do not go into primary care have no basis for that statement. Surveys from Advance and AANP show that the biggest number of NP's work in clinics and hospital-based NP's are a minority. That is remarkable given the barriers that exist in practice.

8. I will not argue the studies that support the quality of care NP's provide. Posters who continue to oppose the validity of these studies have a pre-existing bias to begin with coupled with the fact that no one will be able to produce a perfect study. However, nobody has come up with the challenge of proving that independent NP practice has harmed patients. And no, that poster that mentioned the "missed sepsis" diagnosis does not count. I am a nurse practitioner working in critical care and I can tell you that we've admitted patients in multi-organ failure due to sepsis who were previously seen in the out-patient setting by a primary care physician who did not feel that hospitalization was necessary when they initially presented. Has that tarnished my opinion of the entire medical profession? of course not.

9. This is not a discussion arguing the need for attaining the highest level of nursing education. I am not advocating for the DNP nor the right to be called "doctor" based on one's academic degree. There is no point in suggesting that NP's feel superior to others in the nursing field. The NP role is a distinct role.

10. Finally, I have no vested interest as a nurse practitioner in becoming an independent provider. I am an Acute Care Nurse Practitioner in Critical Care at a medical center operating under one of the top nursing, pharmacy, dental, and medical schools in the US. We have primary care NP's seeing patients in our many clinics as well.

I will never be "independent" in this setting. I am in awe of the expertise of the double and triple boarded physician specialists I collaborate with everyday. But our patients accept for example that a nurse practitioner will be placing their loved one's triple lumen central venous catheter so that we can provide IV vasopressors and monitor hemodynamic parameters.

The medical center have always fostered this spirit of collaboration between nurses and physicians. As one of our chiefs once remarked, "medical students and house officers need to learn to work collaboratively with nurse practitioners because this is the trend in healthcare now". It's time for everyone to play nice in this sandbox.

[BlueDevil,DNP, DNP, RN]

Great post Juan, I agree with you completely. Neither do I have a vested interest in NPs as independent providers in other states, since I already enjoy that status. I do think it is inevitable at this point.

I am in primary care and plan to stay here, at least for the foreseeable future. If I left it, it would be for an opportunity to work as a provider in public health that also provided an opportunity to impact policy, such as one of the RWJ funded clinics in disenfranchised communities. However, we are city dwellers, through and through, so that would have to be an under served urban community, as my family is not interested in living in the sticks, lol. I am earning extremely good money for what I do right now, but once we are not helping to fund private school, college and graduate school educations for 7 children, that will no longer be a consideration. Our retirement is set, and I am not worried about income or "lifestyle" beyond refusing to live in the boonies. I have no problem commuting a reasonable distance to an area of need, but I'm not going to live in Appalachia or what have you.

I have friends and colleagues in other disciplines, and some of that they do sounds interesting, and some of them have much more demanding jobs regarding schedule, etc. I would not do hospitalist work for any amount of money, for example. None of them has a job with as much variety as I see, nor do they have the opportunity to fine tune their practice the way I do. I can literally decline to treat any disorder I feel necessary (chronic pain, anyone?) or trend my practice toward any specialty that interests me. I have carved out my own niche in orthopedics, for instance. It takes >8 weeks to get an appointment at the ortho office, and if you aren't going to have surgery they don't see the point in non-surgical candidates taking up spots on their schedule. Some PCPs, whether MD/PA/NP, are not comfortable with interventional ortho. I do a lot of sports medicine, work with 2 high school athletic teams and provide bursa injections, arthrocentesis, Viscosupplementation, steroid injections, etc. in the office. I enjoy it, it is fun and interesting, and pays exceptionally well, but I'd never leave primary care to do it FT. I just enjoy the hell out of most of my patients, especially the kids. I go home every day knowing I've really helped a few people and I find it extremely rewarding.

I also really like the complex medical patients on my panel; they challenge me and keep me sharp. I'd be bored stiff if I only saw other provider's patients for follow up. I have a 5 year old with a glioblastoma and leukemia. I have HIV patients, and one with HCV and encephalopathy waiting for her transplant; lots of complex cardiac and renal patients. Sure they all see their specialist(s) twice a year, but I manage them the rest of the time- yeah naysayers, all by myself.

I know my weaknesses, such as dermatology- weird rashes outside the obvious just have to go see someone else because chances are I don't know. A few weeks ago I was looking at something I felt fairly strongly was a disseminated gonococcal infection. When the GC came back negative I was stumped. Sent her to derm, turns out she had diffuse cutaneous systemic sclerosis. Well, I admit I'd probably not have come up with that anytime soon, although I had put her on a ton of prednisone and ordered the rheumatoid panel before I sent her off to derm. But that diagnosis was not coming to mind, lol. Derm outside of shingles, eczema and urticaria is not my forte. Maybe I'll take some more CEUs! It was still fascinating, and I enjoyed learning all about it and being a small part of her case. I wouldn't give that up just because it isn't my comfort zone.

I think of that as a perfect example of how primary care is supposed to work. GC belonged in the differential. She did seem to get better with a shot of rocephin initially. When the labs came back negative, referral was reasonable. She was in pain, reported having lost weight without effort, and weak. She needed a diagnosis quickly, so specialty seemed appropriate. Turns out she needed to go to Rheum, but none of us knew that just by looking at her. We just knew she looked like SOS, lol. If she were a regular patient, had I known her, she may never have gotten that ill. Who knows. Primary care works best when it is a relationship.

And for that reason I absolutely believe that every patient needs to see the PCP with whom they feel most comfortable (excepting the quacks, of course). If a patient feels they are most comfortable with an MD/DO prepared provider, than that is whom they should be seeing.