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

forpath · 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.

How has the AMA abandoned primary care?

allnurses Guide · Jun 23, 2008

I am ignorant about recent AMA actions except what is posted here on allnurses.com.

I do know we now have a shortage pf primary care physicians and more specialists in the United States.

Dr. Tammy, FNP/GNP-C · Jun 23, 2008

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?

There is a clear distinction between the generation of best evidence and ultimately how evidence is implemented into practice. I feel that nursing practice is based on best evidence in which data is generated from the spectrum of disciplines including medicine, nursing science, philosophy, psychology, pharmacology, etc. It is important to remember that physicians use evidence generated not just from medicine, but also from other disciplines as much as nursing does the same.

The utility of best evidence is directed by our knowledge of science and the scientific process either at the consumer (critique) level or at the investigation (knowledge generation) level. The implementation of evidence into nursing practice, however is informed by nursing philosophy and directed by the nursing process, not by the medical model or allopathic systems. This is what separates nursing, specifically from medicine as well as from all other fields within the health field.

Nursing philosophy serves nursing to provide a rich process by which we can translate best evidence into practice such as Orem's SCDT, Roy's Adaptation Model, etc. An example of the utility and importance of such can be seen in the use of Leininger's CCT Model to translate how to provide education of an adolescent related to STD's from a Hispanic background. Evidence, in this case suggests that in the absence of providing cultural context to providing nursing care we risk causing cultural harm at worst, or ineffective transmission of information at best.

A low HgbA1c, as an example is a goal of both nurse and physician, but how we get there and those interventions that aid in achieving that outcome are indeed different. Medicine may provide an rx to achieve the goal. An APN will do the same thing in addition to providing counseling to the client and family as a unit in the context of providing holistic and client-centered nursing care. This is specifically why APN practice is growing by leaps and bounds as evidenced by consumer satisfaction--AMA opposition notwithstanding (Present AMA Resolutions).

Although philosophies between the medical and nursing model are quite apparent, the two disciplines (as well as others) share values that help guide ethical decision-making in the context of clinical practice. These include exactly of what you speak: do no harm, or non-malfeasance; veracity; fidelity; responsibility; justice, etc. These values, however are different than specific theory and models that are inherent of the respective professions.

Lastly, consider this: Where would the practice of nursing be if it were not for nursing philosophy guiding practice? Would we really be practicing as an autonomous profession or would nurses be relegated to the tasks by which physicians or other disciplines dictated?

elkpark · Jun 23, 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.

I agree with most of what you said in your post. However, you say "even Mundinger" says DNPs will be comparable/equivalent to physicians as if she's the last holdout who has finally come around to that point of view. Mundinger and her cohort are the only people making that claim, and they are making it without the buy-in of the larger NP community. The "DNP as physician equivalent" is largely a personal crusade on her part, and the rest of the NP community does not seem to be climbing on that particular bandwagon ...

n_g · Jun 23, 2008

So how can anyone here argue that APN's shouldn't at least be regulated by both BON's and BOM's as they do in some states? Many of you are saying is that you do both. If you do both, then doesn't it make sense that both regulate APN's then?

APN's are clearly practicing medicine. Remember that the DO's decades ago pretty much preached the same thing about looking at the patient as a "whole", etc. They even tried to create their own state boards. Look at what has happened. DO training today is nearly indistinguishable from an MD's.

Besides Mundinger's study which hardly holds any water, there aren't much data out there comparing NP's and MD's. What if the MD's start to get serious and start to do real studies? How confident are the people here that the studies will unequivocally show that NP's are just as good as MD's, even in all areas of primary care?

This is what people don't get. We have it good today. All we need to do is go to NP school for 2 years. I fear, and with good reason, that if the MD's start to really scrutinize the DNP and training we get, the training will get longer and harder. There will be more regulations, more cert exams, re-cert, etc. The same BS that MD's have to go through to practice. Is that the kind of regulation NP's want? Why do you think that the MD training got so long? Because it's heavily scrutinized field. A few people screw up and they tack on one more year of training for everyone. Something like that will happen to NP's if we allow these ivory-tower figures like Mundinger to lead us off the cliff.

forpath · Jun 23, 2008

There is a clear distinction between the generation of best evidence and ultimately how evidence is implemented into practice. I feel that nursing practice is based on best evidence in which data is generated from the spectrum of disciplines including medicine, nursing science, philosophy, psychology, pharmacology, etc. It is important to remember that physicians use evidence generated not just from medicine, but also from other disciplines as much as nursing does the same.
The utility of best evidence is directed by our knowledge of science and the scientific process either at the consumer (critique) level or at the investigation (knowledge generation) level. The implementation of evidence into nursing practice, however is informed by nursing philosophy and directed by the nursing process, not by the medical model or allopathic systems. This is what separates nursing, specifically from medicine as well as from all other fields within the health field.
Nursing philosophy serves nursing to provide a rich process by which we can translate best evidence into practice such as Orem's SCDT, Roy's Adaptation Model, etc. An example of the utility and importance of such can be seen in the use of Leininger's CCT Model to translate how to provide education of an adolescent related to STD's from a Hispanic background. Evidence, in this case suggests that in the absence of providing cultural context to providing nursing care we risk causing cultural harm at worst, or ineffective transmission of information at best.
A low HgbA1c, as an example is a goal of both nurse and physician, but how we get there and those interventions that aid in achieving that outcome are indeed different. Medicine may provide an rx to achieve the goal. An APN will do the same thing in addition to providing counseling to the client and family as a unit in the context of providing holistic and client-centered nursing care. This is specifically why APN practice is growing by leaps and bounds as evidenced by consumer satisfaction--AMA opposition notwithstanding (Present AMA Resolutions).
Although philosophies between the medical and nursing model are quite apparent, the two disciplines (as well as others) share values that help guide ethical decision-making in the context of clinical practice. These include exactly of what you speak: do no harm, or non-malfeasance; veracity; fidelity; responsibility; justice, etc. These values, however are different than specific theory and models that are inherent of the respective professions.
Lastly, consider this: Where would the practice of nursing be if it were not for nursing philosophy guiding practice? Would we really be practicing as an autonomous profession or would nurses be relegated to the tasks by which physicians or other disciplines dictated?

Thank you for your post.

While I have no background in Orem, Roy, Leininger, etc (I will look into them), I have to wonder: How much of this is used on a daily basis by APNs? That must take a ton of time, upwards of 1 hour to properly counsel a client and his/her entire family. I have seen many posts on this and other sites where APNs are seeing upwards of 55 patients a day. How can one see that many patients and still be "providing counseling to the client and family as a unit in the context of providing holistic and client-centered nursing care." Are there enough hours in the day? And why are they not called patients? What is a client?

Second, let's look at the so-called holy grail study of Mundinger et al. from JAMA 2000, which DNPs/APNs point to frequently. That study failed to disprove the null hypothesis-that there is no difference in outcome between NPs and MDs/DOs. APNs like to point to it as proof that they are "just as good, if not better" than MDs/DOs. Leaving aside all the reasons why that study was not the best, why did nurses not OUTperform MDs/DOs? It seems as though the integration of a holistic nursing component with psychology, philosophy, nursing science etc should have run circles around MDs/DOs and all patients in the NP group should have been cured of high blood pressure, diabetes, etc.

I can appreciate that patients, sorry clients, often would prefer to be seen by someone who spends more time with him/her. You can't help but feel a personal connection there. But, is satisfaction the most important metric?

"This is specifically why APN practice is growing by leaps and bounds as evidenced by consumer satisfaction" is a direct quote from your post. There are many ways in which one can increase patient satisfaction, but may have nothing to do with quality of care and outcome. If one wants to argue that nursing philosophy and implementation add something to clinical care that the allopathic model does not, so be it. But the proof is in the pudding.

And studies have shown that patients are less likely to sue a praqctitioner with whom they have a good rapport...regardless of the quality of care.

MAISY, RN-ER, BSN, RN · Jul 3, 2008

For the first time I was seen by a NP for a medical exam-the difference between the exam I received by this NP and every other doctor I have ever seen in my 40+years was night and day! It was the comprehensive exam that is in my advanced assessment book! I have had only one other exam that was close to this complete assessment and that was an endocrinologist!

I have had the pleasure of working with great doctors and great NP's-I can tell you from my experience the NPs are requested often....the good doctors too! The reason behind the requests....for both groups is communication and not rushing the patient. So where does that leave the AMA...maybe physicians need to go back to school for communication, patient relations and a few psychology classes. I might never go to a doctor again. I won't be treated as a second class citizen, and I believe doctors resent when they are questioned about decisions, and or, asked for treatments or medications they themselves are not knowledgeable about.

The general public is becoming very healthcare saavy-maybe physicians are realizing they are now providers of service....no one NEEDS to see them, there are alternatives.

As for UAPs or even paramedics, while I agree we all have our place in the hospital flow....AS LONG AS MY LICENSE IS CONTINGENT ON THE ACTIONS OF ANOTHER who I am responsible for....THEY MUST ANSWER TO ME. I don't make the rules, I just follow them.

Maisy;)

menetopali · Jul 11, 2008

if i may...

DNPs are and will continue to be licensed by the state BON, not the SBME. (as a side note, DOs are licensed by a separate board than MDs in AZ at least). as i complete my DNP, i will enter practice with a world view different than MDs or DOs but i will be practicing in the same arena.

UAPs (CNAs/ER techs/ et al) that report to RNs are operating under the license of the RN who directs them are (and should be) regulated by the BON, in a similar fashion individuals who act on behalf and under the license of a physician (PAs / MAs) are regulated by the BOM. the AMA attempting to claim encroachment by another profession is dissimilar to the concern of UAPs encroaching upon the role of nurses.