Advanced Practice: Still nursing and holistic or medical model with nursing approach?

[WKShadowNP]

I read an article today for an assignment I have that stimulated my thinking regarding our role (my future role). It describes Watson's holistic model and goes on to say that the five domains of primary practice are connection, consistency, commitment community, and change. I find this interesting because I like being part of a team and don't want to have a divisive perspective that one is better than the other. Unless I go to medical school, I will not have their knowledge and experience. But I will be prepared, and am being groomed to fulfill a role—call it physician or nurse extender. I am to practice in an advanced capacity and sure I will rely on more knowledgeable persons (physician and NP or PA alike) to attain competency and excellence. I want to add that I don't know why it has to be one or the other. I've seen very caring and holistic physicians. They may identify the problems from a medical standpoint, but they still assess the person-in-environment.

So, I was interested in your opinions regarding the nursing model versus the medical model or anything in between and if this article aligns with your opinion.

Jules A, I'm particularly keen to see your response because I admire your wisdom here.

Medscape: Medscape Access

[BostonFNP, APRN]

Look just around this site at how many people are posting about how they are only interested in nursing because they want to become NPs (or CNMS, or CRNAs -- fortunately, us CNSs are largely spared this phenomenon, since the general public doesn't know about us ...), asking about direct entry programs, or asking which graduate schools they can get into straight out of their BSN program.

I did post some numbers for you above about years or RN experience for FNPs.

I don't see people entering the profession interested in being providers as a totally "bad thing". It's drawing motivated, smart, academically successful, and diverse individuals into nursing that may have ended up in another healthcare role otherwise. I mean look at all those people interested in medical school that just want to be orthopedic surgeons, or people interested in PA school that just want to be PAs. Don't get me wrong it's not all good, it's just not all bad either.

[BostonFNP, APRN]

Yes, but it doesn't specify whether or not that includes the years as an NP. When I completed the ANCC role delineation survey as a CNS, I listed the total years I have been an RN, which includes the years I was a generalist plus the years I've been a CNS, because I've been an RN all those years. Isn't that how most nurses would answer that question (how long have you been an RN)?

"The average number of years of experience the Family nurses had as an RN was 19 years.The respondents also reported on average 10 years of experience working as a NP."

The question is: Q5: How many years of experience do you have as:a registered nurse? a nurse practitioner?

It looks like people answered like you did from glancing at the data. NOt a great way to ask that question...

Even so, that moves the number to one that closer matches the AANP number of 9-10 years.

[WKShadowNP, DNP, APRN]

Re Nursing theory... I think there may have been a time when it was useful.. I loved the nursing model (assessment-nursing diagnosis- care plan) as an undergrad-- i think it gave me a theorectial framework for what I was doing. As an APRN, the medicai model is easier.. evaluation- diagnosis- treatment.... I think polictically it makes sense to stay with nursing.... I think nursing theories have helped us establish and advocate for our profession... Now aprn crosses over to medicine-- mds and aprns are all taking care of or treating patients... for psych, the decade of the brain in the 90's made us more biological and all those new psych meds came along... I was initially trained in psychodynamic psychotherapy (meds came later for me) and it was a great framework for psych.. The field, now called the industry, is evolving and now aprns and psychiatrists are mostly doing the same job...

I really relate to that. I can see the scientific method to the ADPIE approach and then supplement it from an advanced assessment and diagnosing perspective. Substitute the nursing diagnosis for a medical, et voila!

[anh06005, MSN, APRN, NP]

Ugh, I still struggle with this. I get my own paper charts and put them away, while everyone else gives them to the MA. I feel like a dick asking someone to do grunt work. I'm working on it... By the time I'm being paid for productivity I'll have learned that it's okay to focus on tasks that increase my productivity.

I do the same thing. If I'm not busy I will help out. If I am busy I will delegate more. I'm not going to be the one to twiddle my thumbs while everyone else is working, though, just because the work that can be done isn't done by the physician. I've always tried to make it seem that we are all equals on the team. I can't do my job without the secretary and nurse. They can't do their jobs without me.

[PG2018]

I really can't stand when NP's tout that physicians have a superior knowledge because of "Med School". Med school doesnt make the physician smart or competent to practice. They have yet to specialize and don't know more than a nurse with 4 years of experience (which is why they ask you what you would do). The only difference is they are thrust into the supervisory role and have to shoulder responsibility (which you also do as an NP). NP's need to develop more pride and be mindful of their experience and education. My advanced pharm teacher was an NP and blew MD's out of the water with her knowledge. She was wicked smart and very, very, good at her practice both as an NP and an educator. Most NP's have at least 6+ year of experience as a nurse prior to going to school. I think thats a fair amount of time in healthcare (its the same as some of the long residency programs) to have a solid foundation before going to learn advanced practice. Stop putting yourselves lower than a doctor because its what they want! The doc associations want control because they fear (and know) what is coming down the pipeline. They also have the money to lobby which nursing lacks (but is gaining ground on).

NP's can perform equal and in most cases better care than a doc for less. Of course if you were a doc would you want to take a paycut? I dont even think med school needs to be 4 years, it could easily be condesnsed into 2 years and residency programs could also be shaved down a bit. The whole thing is a big song and dance so they can say "we'll we put this much time in and are xxx better trained so therefor we are in charge". This just isnt the case anymore. Healthcare is too specialized and we cant expect to know everything about everything!! Long gone are the days where I give up my chair so a Doctor could sit in my seat. He can pull one right up next to me and roll his sleeves up just as he would expect from me. Grow a set NP's, become the future of medicine! You do practice that after all and not nursing theory!!

Docs have the edge on surgery, something that they are trained to do. I think NP/PA's are starting to crack this nut as well and are being allowed to perform minimally evasive procedures in some practices (cysto and derm for example). My vision of the future is NP's managing primary care with docs being specialist/surgeons.

Many medical programs around the country are shaving down the time it takes to become a physician. It has been argued that four years is not necesary, and that school of thought is taking hold. However, I do believe that the scientific background is pretty important. Granted, much of this knowledge base is forgotten as is any information we don't use on a regular basis. Particularly, that grounding is important to understand a lot of the background details that take place in physiology and pharmacology. You make a good point, however, in that the education of a master's trained NP is equally insufficient because of the training time. A typical primary care provider completes a three year residence, FP, IM, Peds. Psychiatrists undergo four years (arguably a year too long). This doesn't even speak of fellowship training. Compare this to the 750 hours or so that a NP gets in an academic program, and we're deficient in excess 5,000 hours of clinical practice. Additionally, this isn't unstructured work time. It is time replete with lectures, prescribed readings, M&M, rounding, and other educational activities. Most NPs are doing clinicals and then rushing home to write another paper about some vapid nurse theory or something equally ridiculous like Healthy People 2020. I disagree that NPs are as well or equally prepared. I'm aware of an area psych NP who prescribes extremely low doses of seven or eight meds rather than actually raising any singular medicine to a therapeutic dose. Where's the science, preparation, or experience behind that? Of course, this does not suppose that physicians are all reasonable and prudent clinicians. They have their share of idiots, however, their culture includes the expectation that they be trained scientifically and undergo structured, programmed experience. Many NPs, who may object until the earth shakes, get their clinical experience by "shadowing."

[PG2018]

I do the same thing. If I'm not busy I will help out. If I am busy I will delegate more. I'm not going to be the one to twiddle my thumbs while everyone else is working, though, just because the work that can be done isn't done by the physician. I've always tried to make it seem that we are all equals on the team. I can't do my job without the secretary and nurse. They can't do their jobs without me.

I print out my own documents, but otherwise I don't do anything it doesn't take a clinician to do. Although I often feel bad for having other staff do something I could easily do, I learned a long time ago that everyone has their own job, their jobs are different, and not everyone is equal, i.e. of equal abilities. It's really not my job to do clerical tasks, and in having other staff tend to them I can read journals, take a breather and conduct personal calls and emails, and tend to other business matters when I find a gap in my patient schedule of usually arouned 21 +/- people a day.

[PG2018]

Yes, but it doesn't specify whether or not that includes the years as an NP. When I completed the ANCC role delineation survey as a CNS, I listed the total years I have been an RN, which includes the years I was a generalist plus the years I've been a CNS, because I've been an RN all those years. Isn't that how most nurses would answer that question (how long have you been an RN)?

I wouldn't.

[elkpark]

I don't see people entering the profession interested in being providers as a totally "bad thing". It's drawing motivated, smart, academically successful, and diverse individuals into nursing that may have ended up in another healthcare role otherwise. I mean look at all those people interested in medical school that just want to be orthopedic surgeons, or people interested in PA school that just want to be PAs. Don't get me wrong it's not all good, it's just not all bad either.

I agree with you -- I just hesitate every time someone says, nowadays, that what makes NPs special, different from PAs, etc., is that all NPs, by definition, have years of nursing experience. I think that the population is shifting, and that is going to be less true as each year goes by.

[anh06005, MSN, APRN, NP]

I print out my own documents, but otherwise I don't do anything it doesn't take a clinician to do. Although I often feel bad for having other staff do something I could easily do, I learned a long time ago that everyone has their own job, their jobs are different, and not everyone is equal, i.e. of equal abilities. It's really not my job to do clerical tasks, and in having other staff tend to them I can read journals, take a breather and conduct personal calls and emails, and tend to other business matters when I find a gap in my patient schedule of usually arouned 21 +/- people a day.

Yes when I hit 20-25 a day I usually do more delegation lol. There are occasional days, though, where I may see 10. That leaves me with a bit of time. I need to remember to take my journals with me to the office! I do usually read my prescribers letter if there's a new one. But looking at a screen gets annoying after a while.

Just wanted to chime in again and say nothing is wrong with delegation and I see where y'all are coming from. Won't be long before someone misconstrues what I meant....

I just still like the easy stuff sometimes if appointments allow.

[Jules A, MSN]

Just wanted to chime in again and say nothing is wrong with delegation and I see where y'all are coming from. Won't be long before someone misconstrues what I meant....

I just still like the easy stuff sometimes if appointments allow.

I do remember having to resist the urge to "help out" when I first graduated however I believe doing tasks a physician would never touch separates us from physicians and it is a slippery slope. It is confusing to the team and more importantly confusing to the patients. If it isn't a provider job I don't do it. Never. The phone could be ringing off the hook and I will never answer it unless it is ringing at my desk. I demand high end wages and function exactly the same as the psychiatrists.

Early in my NP career when the hospitals had just started using psychNPs there was the misguided suggestion that NPs should do psych patient placement in the EDs on weekends if a socialworker wasn't available. My medical director who pushed back on this ridiculous suggestion told me "Its medication management only, baby. If you start making insurance calls next thing you know they will expect you to take your own vitals. I'm not paying you $80 an hour to do that".

[anh06005, MSN, APRN, NP]

I do remember having to resist the urge to "help out" when I first graduated however I believe doing tasks a physician would never touch separates us from physicians and it is a slippery slope. It is confusing to the team and more importantly confusing to the patients. If it isn't a provider job I don't do it. Never. The phone could be ringing off the hook and I will never answer it unless it is ringing at my desk. I demand high end wages and function exactly the same as the psychiatrists.

Early in my NP career when the hospitals had just started using psychNPs there was the misguided suggestion that NPs should do psych patient placement in the EDs on weekends if a socialworker wasn't available. My medical director who pushed back on this ridiculous suggestion told me "Its medication management only, baby. If you start making insurance calls next thing you know they will expect you to take your own vitals. I'm not paying you $80 an hour to do that".

I guess the difference may be that I'm salary so I feel I should be doing something productive. I do some CEU and research stuff on the clock but, again, can only stare at a screen so long.

In the clinic I do some of the little things in it is so small - besides me there are 5 people in there. Patients know who is who. We are a little family basically and I love that feel. But, again, I see where you guys come from. As I gain more experience my thoughts may change as well. I have only been practicing as FNP since February.

I do think that when places first utilize NP's or PA's they don't know where we fall exactly. Just as your employer thought y'all could do the psych placements in lieu of MSW. I'm glad your director nipped that in the bud.

Also makes me glad to work 4 10's and off weekends and holidays....I don't envy hospital workers much anymore.

[PG2018]

I agree with you -- I just hesitate every time someone says, nowadays, that what makes NPs special, different from PAs, etc., is that all NPs, by definition, have years of nursing experience. I think that the population is shifting, and that is going to be less true as each year goes by.

You do realize that also until very recently most PAs entered their schooling with any number of years of healthcare experience. Many were paramedics or military medics. Others were RTs, RNs, and any other allied field. Kids don't really finish undergrad and jump straight into PA school the prerequisites for which surpass that of RN training. My wife's kid sister is trying to get into PA school. It's really hard.