Should NPs become COMPLETELY independent?

[BS, NP]

wow....there are some well-informed folks on here.....yeah...no one should be downplaying another profession......that doesn't help.....I think it is truly a semantic debate here....be it DOCTOR is a professional title but we all know a euphymysm for a medical caregiver.......who here has not been called 'doc' by your patients???...but....who should be called physicians?? some seem to think we should.....well, if we're arguing for rights as advanced practice nurses why would we WANT to be called a physician....we have to be careful what we are asking for here....it is becoming a slippery slope.....we may lose the support of those who are well established and on our sides....we are NOT physicians....some NPs argue that doctors of chiropractic and optometry carry the title physician while they don't fully care for the entire patient in the same medical manner.........let the non allopathic and osteopathic practitioners of optometry and chiropractic have the title I suppose....traditionally they always have.....fighting for the same or similar RIGHTS is a different story....

I've been giving it alot of thought and really trying to see the big picture......people are getting so hung up on titles and credentials and wording and program curricula......arguing who's better a PA...an NP.....a physician...??? I used to have the theory that if you took an NP, a PA and a physician right out of school.....I think the physician is hands down more prepared, more skilled, more educated.......but, 10 years 15 years down the road....how much does experience and insight and continued learning and study develop each practitioner? could the PA end up being the brightest and most informed and best medical decision maker...?? yes, I think so....could it be the physician, the NP? sure.....doesn't it depend on all kinds of factors that take priority after education? drive? ability to integrate knowledge and medical literature? experiential and acuity exposure in practice? etc...etc.....

I think the definition on this site sums it up well........ A Nurse Practitioner (NP) is a registered nurse with advanced academic and clinical experience in diagnosing and managing most common acute and chronic illnesses either independently or in collaboration with a physician.

we just want to do what we are doing and be who we are and be rightfully recognized and legitimized for it, no???

no we don't have the same training as physicians.....could we safely take on the primary care needs of the population.......sure.....I think we could..........aren't we pretty much doing that now.....as it is....???? won't we still call on our physician and NP and PA colleagues for insight and expertise and experience when ours falls short.....???? yes...I think we will.......

I guess I kind of enjoy basically being independent and still legal having an attachment to a physician who in many cases knows more than I do......

I guess I don't need to be able to say I'M INDEPENDENT to boost my ego.......while some seem to have that need.....

I've heard some folks make a few decent arguments as to why dissolve of collaborative practice agreements is a good and/or founded thing......such as: a rightful move based on our experience and quality and scope of practice; would free up care for those who have independent clinics should something happen to their physician supervisor (death or move or stop practicing)

I guess the facts are coming in and I'm still on the fence......

can anyone else offer other reasons for why this move is so necessary or deserved....???? thanks........

[BS, NP]

Unless the NP presented each case to me (just like residents have to present to an attending in clinic), I wouldn't want a collaborative agreement. I think those collaborative agreements where 5 or 10% of charts are reviewed are worthless. Reviewing a chart is kinda worthless in and of itself. Most charts say very little and without eye-balling the patient when you have issues, what's the point? It's a personal preference but I wouldn't want a collaborative agreement.

No self respecting PhD would ever go into a hospital and claim they are a doctor. The title Dr in a clinical setting should only be reserved for physicians.

so, if a PhD history professor or researching scientist is in a clinical setting.....you refer to them by their first name since they are not a PHYSICIAN...?? sounds pretty disrespectful to me, Wowza.....

[zenman]

....but, clearly you don't know anything about the multitude of studies that HAVE in fact ranked NP care right up there with physicians in quality, safety and efficiency......(in PRIMARY CARE)......not sure what journals you're reading.....aside from studies.....do you work with any NPs or PAs.....what is your experience with their care?

I think some people question the validity of these studies...and they should...as with all studies. In a study titled, "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors,' you'll find an important statement that "Although all of the randomised trials found no significant differences between doctors and nurse practitioners in health outcomes, the research has important limitations."

Horrocks, S., E. Anderson, C. Salisbury. 2002. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal. 324:819-823.

And another:

“Implications for practice: Despite many studies on the comparability and outcomes of NP practice, the need to identify, clarify, and document the practices of NPs in primary care settings remains. The present survey provides an important and useful first step in providing a systematic way to characterize these practices through a survey of APRNs immediately following their patient encounters.”

Deshefy-Longhi, T., M.K. Swartz, and M. Grey. 2008. Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study. Journal of the American Academy of Nurse Practitioners. 20(5):281-287.

[BS, NP]

I think some people question the validity of these studies...and they should...as with all studies. In a study titled, "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors,' you'll find an important statement that "Although all of the randomised trials found no significant differences between doctors and nurse practitioners in health outcomes, the research has important limitations."

Horrocks, S., E. Anderson, C. Salisbury. 2002. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal. 324:819-823.

And another:

"Implications for practice: Despite many studies on the comparability and outcomes of NP practice, the need to identify, clarify, and document the practices of NPs in primary care settings remains. The present survey provides an important and useful first step in providing a systematic way to characterize these practices through a survey of APRNs immediately following their patient encounters."

Deshefy-Longhi, T., M.K. Swartz, and M. Grey. 2008. Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study. Journal of the American Academy of Nurse Practitioners. 20(5):281-287.

sure....I agree...of course they should.....and I'm sure there are limitations.....once again.....I'm not saying either way.....they SHOULD or SHOULD NOT be independent with primary care.....just get a bit irritated with the one sided folks on here who go on about NPs having 1/10th the training of physicians and NPs not providing safe care......NPs not practicing medicine....wake up to reality here.....if we're not providing medical care then what do you call this....???? no, I'm not a physician, but I borrow the same functional processes in my practice and use the knowledge I've accumulated as a previous nurse and a nurse practitioner.......if a patient comes in and I gather a history, review of systems, perform a physical, formulate differential diagnoses, perform a diagnostic workup, conclude on a diagnosis, prescribe a pharmacologic or nonpharmacologic treatment for the patient.....what kind of care am I providing then....??? someone please tell me....

[dgenthusiast]

no, I believe you are correct....not many practicing independently........but, why do you have such a problem with this when those who have been practicing independently have shown no decline in safety and no increases in malpractice premiums....is this not evidence of good practice...?

I have a problem because there aren't any studies showing evidence of equal outcomes. There are a lot of poorly done studies looking at useless values (ie. those that have no bearing on medical outcome) like patient satisfaction. In that first study zenman cited, for example, it states:

"Secondly, nurse practitioners and doctors did not necessarily work under similar circumstances or with similar pressures on their time, even in the controlled trials. It is necessary to determine whether the differences between nurse practitioners and doctors in patient satisfaction and quality of care remain if they work under identical circumstances, particularly with the same rates of booked consultations."

That's a huge confounder there. Not only that, the quality of care measures were pretty useless (except for the accurate diagnosis and the medication variables they looked at). They couldn't conduct an analysis of cost but their study suggests that NPs take longer and order more tests to arrive at the same conclusion as the physician. And the meta-analysis looked at studies that seem to focus on common disorders. Big deal. The study itself states that there needs to be more research done looking at whether NPs provide safe care for rare disorders that show up in the clinic.

Unfortunately, there will never be a prospective study comparing NPs/DNPs (without any physician backup if things go wrong) to physicians in order to look at outcomes because I cannot imagine getting IRB approval for something like that. It's unethical.

[dgenthusiast]

so, if a PhD history professor or researching scientist is in a clinical setting.....you refer to them by their first name since they are not a PHYSICIAN...?? sounds pretty disrespectful to me, Wowza.....

You're putting words in wowza's mouth. Where did he/she say that they would refer to the professor or scientist by their first name? Wowza just said that the professor wouldn't be referred to as a doctor and that's pretty understandable because in a hospital setting, patients equate doctor with physician. I personally have never met a non-physician doctor who got upset over something as silly as this. They all seem to understand it just fine...I don't see why it's such a big deal on these forums.

[dgenthusiast]

sure....I agree...of course they should.....and I'm sure there are limitations.....once again.....I'm not saying either way.....they SHOULD or SHOULD NOT be independent with primary care.....just get a bit irritated with the one sided folks on here who go on about NPs having 1/10th the training of physicians and NPs not providing safe care......NPs not practicing medicine....wake up to reality here.....if we're not providing medical care then what do you call this....???? no, I'm not a physician, but I borrow the same functional processes in my practice and use the knowledge I've accumulated as a previous nurse and a nurse practitioner.......if a patient comes in and I gather a history, review of systems, perform a physical, formulate differential diagnoses, perform a diagnostic workup, conclude on a diagnosis, prescribe a pharmacologic or nonpharmacologic treatment for the patient.....what kind of care am I providing then....??? someone please tell me....

I think most of your colleagues on this forum would vehemently disagree with you here. They would say they're practicing advanced nursing rather than medicine. I mean, don't get me wrong, I think that they're practicing medicine too. If walks like a duck, looks like a duck, and quacks, it's a duck. But it looks like if a nurse practices medicine, it falls under the category of advanced nursing. Otherwise, you'd have to be completely regulated by the BoM.

[cruisin_woodward]

just did a debate on this subject for my health policy class...I was assigned the "con" stance. We had to argue that "nurse practitioners should NOT have full autonomy"...we lost. I thought we had some good arguments, however, they shot them all down with very good arguments. We attacked their data...they attacked ours. We argued education and residency...they had an answer to it all! Needless to say, we lost...

[Jstand]

I have a problem because there aren't any studies showing evidence of equal outcomes. There are a lot of poorly done studies looking at useless values (ie. those that have no bearing on medical outcome) like patient satisfaction. In that first study zenman cited, for example, it states:

"Secondly, nurse practitioners and doctors did not necessarily work under similar circumstances or with similar pressures on their time, even in the controlled trials. It is necessary to determine whether the differences between nurse practitioners and doctors in patient satisfaction and quality of care remain if they work under identical circumstances, particularly with the same rates of booked consultations."

That's a huge confounder there. Not only that, the quality of care measures were pretty useless (except for the accurate diagnosis and the medication variables they looked at). They couldn't conduct an analysis of cost but their study suggests that NPs take longer and order more tests to arrive at the same conclusion as the physician. And the meta-analysis looked at studies that seem to focus on common disorders. Big deal. The study itself states that there needs to be more research done looking at whether NPs provide safe care for rare disorders that show up in the clinic.

Unfortunately, there will never be a prospective study comparing NPs/DNPs (without any physician backup if things go wrong) to physicians in order to look at outcomes because I cannot imagine getting IRB approval for something like that. It's unethical.

Seems like this discussion comes up time and time again on these boards and you stick to your guns that research is what will save the day and make the decision for you. The true point is that the vast majority of the population doesn't need research to tell them that independent practice for nurse practitioners is a good thing for everyone, well except maybe for physicians. This can improve access to care and reduce costs by increasing the amount of competition in the market for primary care services. One statement in your post graphically illustrates how silly your argument is. Can NPs provide safe care for "rare disorders" that show up at the clinic? What this basically says is that you want the overwhelming majority of the population to lose convenience, timely access, and reduced costs because of a couple of rare instances that just might pop up at the clinic every couple of years. Is that what you are trying to tell us?

[BS, NP]

I have a problem because there aren't any studies showing evidence of equal outcomes. There are a lot of poorly done studies looking at useless values (ie. those that have no bearing on medical outcome) like patient satisfaction. In that first study zenman cited, for example, it states:

"Secondly, nurse practitioners and doctors did not necessarily work under similar circumstances or with similar pressures on their time, even in the controlled trials. It is necessary to determine whether the differences between nurse practitioners and doctors in patient satisfaction and quality of care remain if they work under identical circumstances, particularly with the same rates of booked consultations."

That's a huge confounder there. Not only that, the quality of care measures were pretty useless (except for the accurate diagnosis and the medication variables they looked at). They couldn't conduct an analysis of cost but their study suggests that NPs take longer and order more tests to arrive at the same conclusion as the physician. And the meta-analysis looked at studies that seem to focus on common disorders. Big deal. The study itself states that there needs to be more research done looking at whether NPs provide safe care for rare disorders that show up in the clinic.

Unfortunately, there will never be a prospective study comparing NPs/DNPs (without any physician backup if things go wrong) to physicians in order to look at outcomes because I cannot imagine getting IRB approval for something like that. It's unethical.

so, umm.....really curious here........why are you and any of your other anti-NP cohorts on this board again....???? this is a nurse forum and an NP link within the forum........???? I don't think I've ever truly heard the handful of you who think NPs are poorly trained clinicians EVER say anything good about them.....understandably, this is a forum for freedom of thought and opinion....but why don't you go to a medical forum with your perceptions and opinions......anyhow, I'm done responding to u and your buddy 'wowza'..... NPs will continue to thrive and fluorish and be utilized for what they are capable of doing despite your take on it.......

[BS, NP]

I think most of your colleagues on this forum would vehemently disagree with you here. They would say they're practicing advanced nursing rather than medicine. But it looks like if a nurse practices medicine, it falls under the category of advanced nursing. Otherwise, you'd have to be completely regulated by the BoM.

I mean, don't get me wrong, I think that they're practicing medicine too. If walks like a duck, looks like a duck, and quacks, it's a duck.

ok....? so, you agree that I'm practicing medicine, TOO....and since I walk like a duck....I must be a duck ( or at least one functioning in a similar role as said duck) ---this is per you......

so, I'm practicing medicine too.....but at the same time I'm not.......

ok....if it makes YOU feel better.....I don't provide medical care.....I provide advanced nursing care....

[dgenthusiast]

Seems like this discussion comes up time and time again on these boards and you stick to your guns that research is what will save the day and make the decision for you. The true point is that the vast majority of the population doesn't need research to tell them that independent practice for nurse practitioners is a good thing for everyone, well except maybe for physicians. This can improve access to care and reduce costs by increasing the amount of competition in the market for primary care services. One statement in your post graphically illustrates how silly your argument is. Can NPs provide safe care for "rare disorders" that show up at the clinic? What this basically says is that you want the overwhelming majority of the population to lose convenience, timely access, and reduced costs because of a couple of rare instances that just might pop up at the clinic every couple of years. Is that what you are trying to tell us?

You're right, we do keep arguing the same things over and over again. And neither of us are going change our minds. You're of the opinion that no evidence is needed to move forward while I'm skeptical and want evidence before okaying something. If it makes you feel better to think that I want to inconvenience the "overwhelming majority of the population," go right ahead. Not only that, I didn't make that comment in my post. It's directly from the nursing study.

http://www.bmj.com/cgi/content/full/324/7341/819

"...further research is needed to confirm that nurse practitioner care is safe in terms of detecting rare but important health problems."

so, umm.....really curious here........why are you and any of your other anti-NP cohorts on this board again....???? this is a nurse forum and an NP link within the forum........???? I don't think I've ever truly heard the handful of you who think NPs are poorly trained clinicians EVER say anything good about them.....understandably, this is a forum for freedom of thought and opinion....but why don't you go to a medical forum with your perceptions and opinions......anyhow, I'm done responding to u and your buddy 'wowza'..... NPs will continue to thrive and fluorish and be utilized for what they are capable of doing despite your take on it.......

Why don't you try refuting what I said instead of attacking me? I've never been anti-NP. I support midlevels of all kinds. What I don't support, however, is this push towards complete independence and equivalency to physicians that the nursing leaders are pushing for.

[Jstand]

You're putting words in wowza's mouth. Where did he/she say that they would refer to the professor or scientist by their first name? Wowza just said that the professor wouldn't be referred to as a doctor and that's pretty understandable because in a hospital setting, patients equate doctor with physician. I personally have never met a non-physician doctor who got upset over something as silly as this. They all seem to understand it just fine...I don't see why it's such a big deal on these forums.

Why do you need to defend wowza? Can "he/she" not defend "his/herself"? I have never meant anyone besides pompous jerks who were offended by someone calling them by their first name in any setting.