AMA House of Delegates Considers Limits on on Nursing Education and Practice

czyja, MSN, RN · Jun 16, 2008

We are going to have to define our practice in a different way, and I think it could get very complicated and messy. Nusing follows a more holistic model while physicians typically follow an allopathic model of delivery; however, the lines between the two concepts and definitions have become blurry and perhaps antiquated.
G

Agreed.

Osteopathic medicine had similar growing pains -at first it was very different from allopathic medicine, then virtually the same. Now the osteopaths are seeking ways to define and market their "different" approach. Of course the analogy is less than perfect. Osteopathic medical education is almost identical to allopathic med ed these days - and osteopaths are licensed to practice medicine (as are allopaths).

The history of osteopathic/allopathic relations, however, gives one a sense of how much resistance will accompany an expansion of nursing practice. It strikes me that nursing will have to be savvy and play the politics carefully. Fortunately most Americans think the AMA is an organization dedicated to preserving the wealth and privilege of medical doctors and little else. The good news is that nursing enjoys broad public support.

n_g · Jun 16, 2008

The good news is that nursing enjoys broad public support.

But how much of the public supports equating NP's/DNP's with physicians? Less than you think. When it comes to their health, vast majority of the public wants to see a physician.

http://blogs.wsj.com/health/2008/05/07/retail-clinic-closures-not-unlike-the-dot-com-bubble/

But the business model turns out to be a bit trickier than some thought. In recent months,

69 clinics in 15 states have shut down

, including those in Wal-Marts and Medicine Shoppes (a unit of Cardinal Health). CVS is scaling back expansion plans for its MinuteClinics, and may close some of its clinics.

ZippyGBR, BSN, RN · Jun 16, 2008

What right do nurses have to control and supervise UAPs? Do many UAPs not have their own education pathways to certification separate from nursing pathways? Are you not regulating another separate profession with its own scope of practice?

leaving aside the fact the USA has not got to grips with education for rather than training and registration rather than certification for paramedics

if by UAP we are referring to CNA/ Healthcare assistant type roles they are controlled by registered Halth professionals whether that's the floor / ED /OR based staff managed by the Nurses in charge of those clinical areas of therapy assistants managed by PT/OT tc as part of their service ...

what is different is that expanding roles for Nurses and otherHealth professionals is by expanding the skills knowledge and experience of Nurse / Health professional and allowing them to undertake the assessments and formulation of 'diagnoses' with limited / no Physican involvement rather than the situatio with UAPs here more and more interventions or specific techncial skills are being delegated but the Health Professional is still the individual putting his / her name on the bottom of the form ...

Doctors are running scared becasue they are loosing their USP and people have realised they are not demigods ...

forpath · Jun 16, 2008

leaving aside the fact the USA has not got to grips with education for rather than training and registration rather than certification for paramedics
if by UAP we are referring to CNA/ Healthcare assistant type roles they are controlled by registered Halth professionals whether that's the floor / ED /OR based staff managed by the Nurses in charge of those clinical areas of therapy assistants managed by PT/OT tc as part of their service ...
what is different is that expanding roles for Nurses and otherHealth professionals is by expanding the skills knowledge and experience of Nurse / Health professional and allowing them to undertake the assessments and formulation of 'diagnoses' with limited / no Physican involvement rather than the situatio with UAPs here more and more interventions or specific techncial skills are being delegated but the Health Professional is still the individual putting his / her name on the bottom of the form ...
Doctors are running scared becasue they are loosing their USP and people have realised they are not demigods ...

Bolded part #1-I was talking about what someone else posted regarding UAPs being under the control of the Board of Nursing, not how this hospital or that oversees them. If the BON does oversee UAPs, including paramedics, then they are acting in a hypocritical fashion. They are maintaining control so that they can limit the scope of what a UAP can do so as to not encroach on lower level nurses, correct? Like LVNs/LPNs?

Bolded part #2-Why put diagnoses in quotes? Are you suggesting that nurses provide quasi- or pseudo-diagnoses? No. Everyone knows that is exactly what APNs do. They diagnose and they treat. To suggest otherwise is merely wordplay to get around the fact that state laws limit who can/cannot diagnose and treat.

Bolded part #3-By doctors do you mean physicians? Because there are a lot of "doctors" out there that probably have no problem with what is going on. Physicists, literature PhDs, etc. By USP, do you mean "unique selling point"? If so, maybe physicians are upset about that. Just like nurses are upset that UAPs and paramedics, people whom nurses feel have less education and training than them, are encroaching on their turf. Physicians worked hard to get where they are. Why shouldn't they try and protect it?

Demigod is a half god, by the way. You are actually complimenting a physician if you tell them they are so down to earth as to consider themselves only a half god.

ZippyGBR, BSN, RN · Jun 16, 2008

Bolded part #1-I was talking about what someone else posted regarding UAPs being under the control of the Board of Nursing, not how this hospital or that oversees them. If the BON does oversee UAPs, including paramedics, then they are acting in a hypocritical fashion. They are maintaining control so that they can limit the scope of what a UAP can do so as to not encroach on lower level nurses, correct? Like LVNs/LPNs?

the point being the power relationship issues in physician vs . Nurse or physician vs any other Helath professional is total loss of control and oversight ...

UAP have a function to work as 'extenders' of the Health Professional who holds the accountability , i there's nothing to do with hypocrisy here and everything to do with the fact that some in medicine see Nurses and other health Professionals not a peers but as their assistants ... beyond even the physician is 'first among equals' view which seems to persist ...

sometimes physicians are the first among equals when it comes to the MDT and meeting the needs of a patient - usually this is primary care where the family Doctor is the one with the most holistic view as the Health Professional who sees the patient the most and has the best knowledge of the patient

... in secondary care the first among equals is the Nurse becasue Nurses are there and involved in patient management 24/7/365

the fundamental difference between UAP and the Registered Health Professional ( even if they are a 'lower' one such as the EN or LPN is that the registered professional has accountability for the patient and is there to make assessments etc ...

Bolded part #2-Why put diagnoses in quotes? Are you suggesting that nurses provide quasi- or pseudo-diagnoses? No. Everyone knows that is exactly what APNs do. They diagnose and they treat. To suggest otherwise is merely wordplay to get around the fact that state laws limit who can/cannot diagnose and treat.

exactly , but if you don't you start getting people spouting forth excrement aobut 'practicing medicine without a licence' ... the whole pathetic performance over diagnosis is a leftpondian one anyway certainly the convulated stuff of NANDA

Bolded part #3-By doctors do you mean physicians? Because there are a lot of "doctors" out there that probably have no problem with what is going on. Physicists, literature PhDs, etc.

yes registered medical practitioners

By USP, do you mean "unique selling point"?

yes

If so, maybe physicians are upset about that. Just like nurses are upset that UAPs and paramedics, people whom nurses feel have less education and training than them, are encroaching on their turf.

are they when they can sign off for things themselves, work without the presence and /or authority of the Registered practitioner ...

being able to delgate more interventions is not grounds for a turf war you can train anyone with reasonable hand eye coordination to cannulate it doesn't necessarily mean that everyone who can undertake the intervention knows the full hows , whys and wherefores ...

if a patient needs blood taking or an I cannula puttign in i really don't care who does it as long as it;s done safely appropraitely and in a decnet time frame so whether it's a Physician, an RN, a HCA or a phlebotomist from the labs it really doesn't matter, the important question is who is the person that decides 'yes this person needs this test / intervention /medication ' and while it;s still in the hands of the registered Professional i'm not concerned

Physicians worked hard to get where they are. Why shouldn't they try and protect it?

even if it causes more harm than good?

even if it means safe , prompt and effective care is delayed or unavailable to a proprtion of the population?

if you are good at your job customers will come to you , good providers will work with you / for you / offer you a job ...

Demigod is a half god, by the way. You are actually complimenting a physician if you tell them they are so down to earth as to consider themselves only a half god.

a good Physician realises they are a human and that as part of the team they have a part to play, my own thought on this is hospital wise " Doctors behave as poorly as the Nurses let them behave ... us right pondians of course have the advanatage that all our hospital doctors in the NHS are employees or under such terms and conditions regarding their behaviour that they may as well be ... all the professional regulators in the Uk will entertain professional practice complaints about Health professionals who do not behave acceptably and damage patient care through their poor behaviour.

forpath · Jun 16, 2008

the point being the power relationship issues in physician vs . Nurse or physician vs any other Helath professional is total loss of control and oversight ...
UAP have a function to work as 'extenders' of the Health Professional who holds the accountability , i there's nothing to do with hypocrisy here and everything to do with the fact that some in medicine see Nurses and other health Professionals not a peers but as their assistants ... beyond even the physician is 'first among equals' view which seems to persist ...
sometimes physicians are the first among equals when it comes to the MDT and meeting the needs of a patient - usually this is primary care where the family Doctor is the one with the most holistic view as the Health Professional who sees the patient the most and has the best knowledge of the patient
... in secondary care the first among equals is the Nurse becasue Nurses are there and involved in patient management 24/7/365
the fundamental difference between UAP and the Registered Health Professional ( even if they are a 'lower' one such as the EN or LPN is that the registered professional has accountability for the patient and is there to make assessments etc ...
exactly , but if you don't you start getting people spouting forth excrement aobut 'practicing medicine without a licence' ... the whole pathetic performance over diagnosis is a leftpondian one anyway certainly the convulated stuff of NANDA
yes registered medical practitioners
yes
are they when they can sign off for things themselves, work without the presence and /or authority of the Registered practitioner ...
being able to delgate more interventions is not grounds for a turf war you can train anyone with reasonable hand eye coordination to cannulate it doesn't necessarily mean that everyone who can undertake the intervention knows the full hows , whys and wherefores ...
if a patient needs blood taking or an I cannula puttign in i really don't care who does it as long as it;s done safely appropraitely and in a decnet time frame so whether it's a Physician, an RN, a HCA or a phlebotomist from the labs it really doesn't matter, the important question is who is the person that decides 'yes this person needs this test / intervention /medication ' and while it;s still in the hands of the registered Professional i'm not concerned
even if it causes more harm than good?
even if it means safe , prompt and effective care is delayed or unavailable to a proprtion of the population?
if you are good at your job customers will come to you , good providers will work with you / for you / offer you a job ...
a good Physician realises they are a human and that as part of the team they have a part to play, my own thought on this is hospital wise " Doctors behave as poorly as the Nurses let them behave ... us right pondians of course have the advanatage that all our hospital doctors in the NHS are employees or under such terms and conditions regarding their behaviour that they may as well be ... all the professional regulators in the Uk will entertain professional practice complaints about Health professionals who do not behave acceptably and damage patient care through their poor behaviour.

I agree with much of what you say, don't get me wrong. First off, I had no idea what left and right pondian was. I looked it up on urban dictionary and I chuckled. I can understand so much more of your post now.

Peers-What do you consider a peer? Does a physician with 4 years med school and 3+ years residency HAVE to consider a LVN/LPN/RN as his/her peer? If they do not, are they an egomaniac? Does a DNP/FNP HAVE to consider an LVN/LPN/RN as his/her peer? I think realistically, no. You need to have a hierarchy whether people's feelings get hurt or not based on their place in the hierarchy. If you want to move up and be treated as a peer, go back to school. You have to have a solidified team where evryone understands his/her role. I think this is a lot of the problem. What used to be clear with respect to job description is now not so clear.

Should they treat them with respect because they are a human being? Absolutely. I have zero tolerance for people who treat others poorly simply because they have more education. Similarly, I have zero respect for someone who treats someone poorly because they themselves have less education. We have all seen this (nurse vs. resident...or registrar for you right pondians:))

Does a physician HAVE to consider a DNP/FNP as his/her peer? This is where it is getting muddy. From a practical standpoint, physicians have no choice. APNs are here to stay, so why fight it?

Bolded part #2-If only the legal system felt this way. The law does not see the secondary care nurse as first. If they did, physicians could relax a little.

Bolded part #3-I think we all can agree that more studies need to be done before we can say how safe and effective APN care is. Only a couple studies have been done and they are less than stellar. The question is, to whom do you compare the care of an APN? Apparently you can't use physicians, because the model of care nurses provide is different. They aren't practicing medicine, they are practicing nursing. So you can't compare apples to oranges. If a good study is done and nurses provide equal/superior primary care, so be it. More power to them. I would be more than happy to jettison primary care to nurses. It's a dying endeavour from a financial standpoint. It is unsustainable in our current reimbursement climate.

n_g · Jun 16, 2008

The question is, to whom do you compare the care of an APN? Apparently you can't use physicians, because the model of care nurses provide is different. They aren't practicing medicine, they are practicing nursing.

Are APN's practicing nursing? Even Mundinger herself said that DNP's will have the knowledge of a physician and to play it safe Mundinger keeps the DNP's toes in the nursing pool.

I've asked this before and I'll ask again. How many of you think that NP's could argue in court successfully that they are practicing nursing and not in fact medicine?

If your best argument is to point to me statements from the ANA, AANP, AANA, etc where they claim that they are practicing nursing, then I've got a bridge to sell you.

Judges aren't stupid. They look at the facts and they aren't swayed by some proclamations from nursing groups. Take a look at how the CRNA's in Louisiana were barred from doing pain medicine. They lost every single legal challenge even though the ANA and AANA supported them. Something like this could happen to NP's where judges officially rule that NP's needed to be supervised by the boards of medicine.

* The practice of interventional pain management is not the scope of practice of a nurse anesthetist.

* The practice of interventional pain management is solely the practice of medicine.

Taking on the AMA is not like the AANA taking on the ASA. We're dealing with the entire enchilada. If it goes badly, at least we'll know who to blame. Mundinger.

czyja, MSN, RN · Jun 16, 2008

But how much of the public supports equating NP's/DNP's with physicians? Less than you think. When it comes to their health, vast majority of the public wants to see a physician.

I agree - but I dont think the clinics shut down because they were staffed by NPs and PAs. I strikes me that getting healthcare services at the local wallmart might simply be something people dont want to do.

I am not a nurse practitioner (only a humble nursing student) but IMO it is bad idea for nursing practice to position itself as a bargain alternative to physician care.

Dr. Tammy, FNP/GNP-C · Jun 18, 2008

Are APN's practicing nursing? Even Mundinger herself said that DNP's will have the knowledge of a physician and to play it safe Mundinger keeps the DNP's toes in the nursing pool.

That's one of the few things I wish she didn't say. You are right, it by defacto implies that APN's practice medicine when in fact medicine and advance practice nursing and dentistry, podiatry, optometry have certain functions consistent with their discipline and practice that do overlap (e.g. prescribing, diagnosing).

It also sets the tone that we are trying to be equivalent to physicans, when we really are not (e.g. nursing process, theory, models versus medical model) which ultimately is a different product.

Dr. Tammy, FNP/GNP-C · Jun 18, 2008

I am not a nurse practitioner (only a humble nursing student) but IMO it is bad idea for nursing practice to position itself as a bargain alternative to physician care.

Too true. That's why APN's have to stand together and educate the public that physician and APN services are guided, informed and directed by separate philosophies and theory.

forpath · Jun 18, 2008

Too true. That's why APN's have to stand together and educate the public that physician and APN services are guided, informed and directed by separate philosophies and theory.

I agree, but, does the decision making process of an APN only include philosophy and theory? Or does it also include hard data procured from clinical trials and research which then lead to practice guidelines? If so, from where do this data come? From the "physician" side of the street or the "nursing" side of the street? My guess is that the vast majority of an APNs clinical practice knowledge comes from the physician side, while the implementation of that knowledge may have more influence from the nursing side. A low HgbA1c, for lack of a better example, is sought by physicians and nurses alike for diabetics, yes?

And what are the separate philosophies? Physicians have "first do no harm" and "the interest of the patient is the only interest that matters". I realize these sound nice and warm and fuzzy and unfortunately, not every physician follows them, but exactly how different are nurses and doctors when it comes to the overriding philosophies on which both professions are based?

HM2VikingRN, RN · Jun 23, 2008

Since AMA has abandoned Primary Care someone will have to fill the gap. NPs and DNPs are stepping up to the plate.