Nurse Practitioner Restrictions

[travelNP]

I decided to become an ARNP because I knew it would be an empowering career. Although the work of an ARNP and Physician is similar, there are many differences. Physicians tend to use a scientific approach when addressing their patients, due to their rigorous science-based education. ARNPs approach the patient holistically. When I diagnose a patient with Diabetes Mellitus Type 2, I explain what this disorder is and the causes; I explain the treatment plan; I discuss nutrition and physical activity changes; I assess the patients comfort level with their treatment; I encourage the patient to discuss their feelings upon finding out they have this new chronic disorder; and I reassess the patient within a 2-4 week timeline. I am interested in making sure the patient understands their disorder and how they can manage it.

Unfortunately, in Florida there are some limitations on the ARNP that allows physicians to have more power. For example, Physicians can order home health treatment,controlled substances, and open their own practices without having a supervisory protocol. It is frustrating that Florida is one of the few states that has such strong limitations on ARNP scope of practice. For example, ARNPs cannot order durable medical equipment for Medicare patients in Florida. This means I cannot order a low back brace for my patient with chronic low back pain; I cannot order diabetic shoes for my patient with DM Type 2; I cannot order a cane for my patient with Parkinson's.

Moreover, ARNPs cannot prescribe controlled substances, including benzodiazepines that so many of my patients take for their anxiety or insomnia. Currently, I write out the prescription and my supervisory physician will sign the prescription. The only people suffering are my patients because this delays access to their medications. Recently,Tramadol was added to the controlled substance list. I had previously prescribed this medication frequently for my patients with chronic low backpain and severe osteoarthritis. I was not thrilled the day I received a phone call from the pharmacist telling me that tramadol was effectively now a controlled substance.

In addition, ARNPs cannot order home health treatment. This does not make sense to me since I am the primary care provider for many patients and oversee their medical care. So if I have a patient with history of a stroke and hemiparesis, I believe I should be able to order home health physical therapy for them. If I have a patient with dementia and uncontrolled hypertension, I believe I should be able to order home health blood pressuremonitoring for them.

Lastly, I do not like that ARNPs have to have a protocol with a supervising physician. It's as if the physician defines our scope of practice and not the state board of nursing. If I wanted to open up my own practice, I would need a physician to be the medical director. This means I would have to waste a few thousand dollars a month just to pay the physician for having their name on the wall of my clinic. I would be seeing the patients, overseeing the clinic, and reviewing charts, but would still have to pay my supervising physician to do nothing except 'supervise me'.

I am hoping with the Affordable Care Act and the abundance of new people seeking primary health care, that Florida will increase the scope of ARNPs. Working with the ANA, FNA, and other nursing organizations, I plan to fight for these rights. I see myself having my own practice where I see a variety of illnesses and ages. I hope that the care provided will not be based as much on cost as it is today. We already know ARNPs will be a forefront to help with the primary care shortage.

[BostonFNP, APRN]

No clue how a 7.5 minute appointment appropriately treats anything.

Are you sure all 20 providers in the area are being contacted by your secretary for referral appointments? 5 months just seems like an excessive wait.

On my adult unit I also had a patient with long term active addictions issues hospitalized for an intentional OD who was receiving Xanax and Adderall from the PCP. Really??? How is that even considered appropriate?

I guess the same can be said for any specialty but the horrific prescribing I see by PCPs do a disservice to the patients they are trying to help. Imo the patients absolutely would be better served by not being treated at all for several months rather than being mismanaged with some of these regimens.

That's the tough thing, the only psych-MH office in 20 miles that will see people on disability or low-income insurance is a "pill-mill" sort of place: 7.5 minute appointments, no options other than pharmacotherapy. They won't take any patients with substance abuse issues. It's a very difficult area.

I have personally contacted all the psychiatrists in the area, and most of the NP/CNSs. I even go to psych pharma dinners to meet people and build a connection. This is what we have here, and if a patient can private pay or has commercial insurance, it's no problem and they can get great care; let's face it, many that need the most care don't have the funds or a job/insurance.

Sadly I see people with history of sub abuse on narcotics + benzos + stimulants, the "trifecta". What's treating what? They come in as new patients, provider hopping, and I am just honest with them and tell them I won't write those for them without formal ADD/ADHD testing, psych, and pain center recommendations. They move on, but I look at their PMP record and can see other provider have been doing it for them. Some PCPs. Some psych providers. Some ED providers. I call them "legacy scripts" because new patients come in with them, get a month script, and move on.

I think there is a lot of inappropriate prescribing out there from all sorts of providers. I have seen some horrendous combinations from psych and PCPs alike. I have some recent education on psych meds, my colleague physicians that went to med school before SSRIs even existed really don't.

Glad you are out there doing the right thing.

[Jules A, MSN]

I have personally contacted all the psychiatrists in the area, and most of the NP/CNSs. I even go to psych pharma dinners to meet people and build a connection.

I wish we were closer because I could hook you up but applaud and would encourage you to continue attempting to build relationships with your local psych folks. Hopefully they will realize its a two way street because I value the PCPs I'm friendly with who are willing to collaborate on our mutual patients' care.

[guestnurse]

Yes, pretty much the same here in Louisiana

[SCSTxRN]

In Texas, we do have to have a supervising physician in order to prescribe, but not to practice 'advanced nursing'... but there is no distinct supervisory quantity requirements. New NPs and MDs have to face to face monthly, the requirements decrease with experience, and an MD can supervise FTE of 7 NPs or PAs.

Assuming the prescriptive authority agreement is in place, we can RX schedule 3-5. Not sure about DME and home health, as I'm psych.

[Darcy13]

Thank. You That was great, beautifully written . Enter the political forum in your state and start working with your local congressional member that's how you will make changes ! Identify the need quantify it and go for it!

[nursetim, NP]

Tramadol did not become a controlled substance until last year. And as a Florida NP we cannot prescribe controlled substances.

Another thing is that advanced practice nurses should always support each other instead of bringing each other down.

a lot of times, I wish I wasn't allowed to Rx narcs. It's a headache for me. Pt. work me for narcs all the time and it gets tiresome.

[Sisyphus_01]

Never concede that physicians are better equipped due to more hours of training. Anticipate that they will trot out the same story about how physicians have x amount of hours more training compared to x amount of training for an NP. Every time they bring it up ask them for the study that has shown the number of training hours necessary to be competent to be a practitioner. No such study exists. Does anyone think that the orthopedic surgeon I work for is a better orthopedic surgeon because of his rotation through the medical ICU as a resident? Give me a break.

I'm prepared to be flamed for this, but... no... just no. Time spent training is what makes people better, see Malcolm Gladwell's 10,000 hour rule.

NPs are a valuable asset to the patient care team, but they cannot and should not replace physicians. IMHO, NP's wanting to be defacto doctors without going through the training diminishes the perception of nursing as a whole and cheapens what NP's bring to the table.

Nursing is a school of thought and practice that at its heart is very different from the medical model. Respect nursing and allow it to be what it is, a valuable part of patient care, it's not less than medicine, it's different. Hence, there are different roles and different responsibilities. I'm pretty sure that the hospital where I work would flip a lid if a physician tried to give a patient a bed bath or change a patient's brief... that is out of their scope. Plus, I'm pretty sure they'd make a giant mess and as a tech, I'd have to clean it up... lol.

You want to practice in the same way a doctor does without NP restrictions? Go to medical school. This crap is tantamount to a civilian pilot whining that he can't be a naval pilot and demanding that he be allowed to assume the role with his current level of expertise ... dude... you aren't trained to do all the stuff you need to do. You don't like it? Tough. Want to be a naval pilot? Go do the work, get the training. No, being a naval pilot isn't better than being a civilian pilot IT'S JUST DIFFERENT and additional training is required. I'm sure a naval pilot would also have to learn quite a few things in order to become a civilian pilot.

Also, your argument that a surgeon's rotation through ICU as a resident would not impact their ability to be a better practitioner is ludicrous. Where do you think surgical patients go after surgery? Quite often, it is the SICU. Knowing where your patient is going and having seen the consequences of different decisions that were made by the surgeon is a powerful learning opportunity for a budding surgeon.

Here's just a few examples of things a surgery resident would learn in an ICU rotation:

"GY I/II - Surgical Intensive Care Unit Service

A. Medical Knowledge

1. The resident should learn in depth the fundamentals of basic science as they apply to patients in the intensive care unit. Examples include anatomy, physiology and patholophysiology of the cardiovascular, respiratory, genitourinary, gastrointestinal, musculoskeletal, hematologic, endocrine systems, respiratory failure, coronary ischemia, shock, malnutrition, stress ulceration, nonocclusive intestinal ischemia, antibiotic-associated colitis, antibiotic resistance, jaundice, and renal insufficiency.
   
2. The resident should understand the rationale for admission and discharge criteria in the ICU.
   
3. The resident should understand factors associated with assessment of preoperative surgical risk. Examples include evaluation of the high risk cardiac patient undergoing non-cardiac surgery.
   
4. The resident should understand fluid compositions and the effect of the losses of such fluids as gastric, pancreatic and biliary fistulas at various levels.
   
5. The resident should understand the indications for, and complications of blood component therapy.
   
6. The resident should be able to discuss the pathophysiology of respiratory failure.
   
7. The resident should be able to demonstrate an understanding of acid-base disorders, including diagnosis, etiology, and instituting appropriate treatment.
   
8. The resident should be able to discuss the pathophysiology, indications, and complications associated with various modes of mechanical ventilation. Examples include ventilator management of ALI, ARDS and thoracic trauma, as well as weaning from ventilatory support.
   
9. The resident should understand the role of hormones and cytokines in the graded metabolic response to injury, surgery and infection.
   
10. The resident should understand the indications, routes and complications of administration of parenteral and enteral forms of nutrition.
    
11. The resident should understand the factors associated with altered mental status. Examples include traumatic, septic, metabolic and pharmacologic causes.
    
12. The resident should understand the risk factors associated with stress gastritis.
    
13. The resident should understand the causes and treatment regimens for gastrointestinal bleeding. Examples include bleeding from upper and lower GI sources.
    
14. The resident should understand the factors associated with bleeding disorders. Examples include DIC, ITP, hemophilia, coagulopathy associated with shock and hypothermia.
    
15. The resident should understand the pathophysiology of hemodynamic instability. Examples include types of shock, cardiac arrest.
    
16. The resident should know and apply treatments for arrhythmias, congestive heart failure, acute ischemia and pulmonary edema.
    
17. The resident should understand adjuncts to the analysis of respiratory mechanics and gas exchange. Examples include work of breathing, rapid shallow breathing index, CO2 analysis and dead space measurements.
    
18. The resident should understand fluid and electrolyte as well as acid/base abnormalities associated with complex surgical procedures and complications. Examples include massive fluid shifts associated with trauma, shock and resuscitation, high output fistulas and renal failure.
    
19. The resident should understand the pathophysiology associated with endocrine emergencies in the ICU. Examples include thyroid storm, hyper, hypoparathyroid states and adrenal insufficiency.
    
20. The resident should understand the risk factors and common pathogens that are associated with nosocomial infections.
    
21. The resident should be able to discuss the mechanism of action as well as the spectrum of antimicrobial activity of the different antibiotic classes. Examples include carbapenams, extended spectrum penicillins and fluoroquinolones.
    
22. The resident should understand the risk factors that result in multiply resistant organisms. Examples include antibiotic dosing, antibiotic synergy and transmission patterns.
    
23. The resident should be able to discuss the factors that result in an immunocompromised state. Examples include malignancy, major trauma and steroids.
    
24. The resident should understand the pathophysiology of traumatic brain injury and neural disease. Examples include knowledge of intracranial pressure monitoring and maneuvers to normalize ICP.
    
25. The resident should be able to discuss the pathophysiology, presentation, and causes of hepatic failure.
    
26. The resident should be able to discuss the pathophysiology, presentation, and causes of renal failure and indications for intermittent dialysis or continuous hemofiltration. Examples include pre-renal failure, acute tubular necrosis, hepatorenal syndrome.
    
27. The resident should be able to discuss end of life ethical issues. Examples include organ donation and withdrawal of support."
    

SICU Resident Orientation - Training & Education - Trauma, Critical Care, and Burns - Division of Surgery, UCSD

#dealwithit #sorryi'mnotsorry

[nursetim, NP]

I agree with the above.

[BostonFNP, APRN]

I'm pretty sure that the hospital where I work would flip a lid if a physician tried to give a patient a bed bath or change a patient's brief... that is out of their scope. Plus, I'm pretty sure they'd make a giant mess and as a tech, I'd have to clean it up... lol.

#dealwithit #sorryi'mnotsorry

Physicians are more than capable of giving a bed bath, and it is most definitely not outside their scope, and top be honest if the did give bed baths it would give them a better chance to see and inspect the patient than they get otherwise, alas, the reason why they don't is not that as a tech you are more competent then them in the procedure, it's because of 1. money and 2. the fact they don't want to.

You spoke of nursing education and then gave some copy & paste texts from a residency rotation. Have you been to nursing school? Or medical school? A novice RN would meet the learning objectives you just listed for a surgical resident, and experienced RN or ACNP would walk circles around a surgical resident in regards to those topics. And remember, a resident is a practicing physician not a student.

Call you local surgeon's office. Ask if you can come in and see them for help managing your diabetes with nephropathy, see if they would see you.

The fact of the matter lies in that the evidence shows for outcomes; you could go to 4 years of graduate and 4 years of PG education to be a tech, but does that mean you'd do a better job as a tech because of it?

[Jules A, MSN]

I'm pretty sure that the hospital where I work would flip a lid if a physician tried to give a patient a bed bath or change a patient's brief... that is out of their scope. Plus, I'm pretty sure they'd make a giant mess and as a tech, I'd have to clean it up... lol.

I agree with some of your points and do feel that our NP education both with courses and limited clinical hours is deficient to physicians. FWIW I'd flip my lid too if I was asked to do a bed bath. Not happening, not that I can't do it, but I have no interest and no time for it. I don't do anything they wouldn't ask a physician to do.

[Dranger]

As a bedside MICU RN I have at least a baseline proficiency with everything you copied and pasted. It's not secret knowledge and most of the disease states you listed I deal with on and a day to day basis with physicians expecting me to have a firm physiologic understanding of while taking care of their patients.

A general surgeon is not going to remember everything he learned in an ICU rotation. I remember asking one of the younger docs questions about vasopressor and antibiotics coverage post op and contraindications associated with certain antibiotics (with present comorbidities) and he stopped me and laughed while saying, "Dude I just cut you probably have a better grasp of those details than I do." In all honesty he was probably being modest but it really makes sense from his perspective. He is highly trained and proficient in being an attending general surgeon, just because he had an ICU rotation doesn't mean he will retain everything. Physicians also work off of learned experience, do you honestly think an attending will remember everything from his STEP exams? No.

Yeah patient's go to the SICU but there is also usually an intensivist and other consultants working on the same patient. Do you know how hospitals work?

I agree NPs should not replace physicians and the NP education system needs a lot of overhaul but you need to think things through before you post.

[PG2018]

Medicine is like any learned skill. The skill may perish. At one point, I learned the difference between an appositive phrase and a prepositional phrase. Today, I know they exist, and I believe they are demarcated by commas. Beyond that, I don't know the difference, however, if it concerned me enough to even "Google it" I would probaby begin to remember and be able to select said phrases from sentences.

Likewise, I once learned the difference between sine, cosine, and tangent. I have no idea what those are other than buttons on a big calculator now. I don't remember how to calculate it or why one would need to do so.

These are two examples of "specialty" knowledge. All physicians and APRNs (et al.) need to learn specialty knowledge at some point so that it becomes part of their awareness. This also makes later reference easier. However, it's a given that they will lose the vast majority of what they've learned. I really admire some of the seasoned FP docs because they have historically managed a lot of stuff, and in many parts of the U.S. they still round in critical care settings. That's a heck of a lot of breadth for one person, but to be true I know that regarding the niche field of psychiatry they often screw it up. I point this out because just because you learn something doesn't mean you're an expert, and just because you learned something doesn't mean you still know anything about it beyond the existence of it. You are doing really well to retain 10% of education and training on a long-term basis.

I was once a paramedic (quite a while ago), and I was a RN in the ED (not that long ago). Interestingly, I can easily remember most of the ACLS algorithms of 15 years ago, but I can't for the life of me remember what I learned three years ago. Similarly, there are a lot of things from nurse school that were covered that I don't remember. For example, where is or what body part is a fundus? It had something to do with postpartum, and somebody is supposed to rub it. But I don't know exactly what one would be rubbing, lol. I'm in psychiatry so with respect to mental health I could not for the life of me babble off some RN list of therapeutic communication techniques (or even care to see such a list), but I can surely discuss the whys and hows I choose a given atypical. I'm compartmentalized to my field. Most other specialists are compartmentalized to their field. It's entirely human nature to cast aside knowledge that isn't a priority. The more you work with one area the more you'll learn about it and forget about the rest. If I could pick any one other field to know and complement my niche it would be endocrinology. I like neuro but am bored to tears with neuromuscular disorders. For pleasure, I'd like to know more about sports medicine because I'd just like to. However, I've forgotten the names of so many muscles and other components. I was shockingly surprised when my mother-in-law called me the other day talking about her aching butt and how her doctor had named a muscle she couldn't recall the name of. He'd told he was afraid it would "erode" her sciatic nerve. Immediately "piriformis" ran out of my mouth, and she said "yeah, that's the one." And I thought "how did I know that?"