Hello. I am considering NP and PA school. I have a few years of experience as an ED Tech in a Level 3 Trauma Center in California (busy, but not too intense). Our ED is staffed with PA's no NP's.
I have a few questions about clinical differences between NP's and PA's. I know that PA's seem to have a great ability to work in surgery specialties like ortho, neuro, peds, and cardio surgery. They do pre and post surgery exams, order interprets tests, and prescribe meds (at least in 47-49 states). Are there any NP's on this forum who do this? Are there any in California who can comment?
Second. I know that most PA schools have a much longer clinical component than do NP schools. I have been told it is because NP's already have so much clinical experience as nurses. But can you really compare the two? In our ED, the nurses are not making differential diagnoses, determining etiology of disease, etc. etc., they are monitoring the pt's overall state and response to the treatment ordered by the Physician (or sometimes PA). Therefore, does this experience compare to the rigorous training PA's get in diagnosing?
Part of my interest in medicine is the actual procedures themselves. I want to do chest tubes, central lines, suturing, first assistant surgery, etc. etc. Are there any NP's out there who are doing this?
Finally, I know some people (including some nurses) who deride the "nursing diagnosis" concept. Can anyone offer up a brief rationale for how nursing diagnoses are of value to an NP in clinical practice?
The issue is that of competency, professional development, autonomy and ultimately accountability. Is a nurse practitioner competent to provide primary care? If not this is an education and training issue. Does being competent include knowing when to refer a patient to a physician or APN specialist? How does this competency differ from that of a physician, and her ability to recognize the need to refer and the fact that there are no supervision requirements in place for primary care physicians? Why does an NP who is deemed compentent in the provision of primary care need supervision over NP practice--especially by someone outside of nursing?
Has any NP reading this graduated from an NP program where the terminal objective reads,
"The NP graduate will be competent to provide primary health care services for clients and families across the life cycle with acute and chronic disease, but only with proper supervision from someone outside of the nursing profession."
Physicians are licensed to practice medicine. Nurse practitioners are not licensed to practice medicine. Nurse practitioners are licensed by Boards of Nursing. Nurse practitioners are afforded the opportunity to practice advanced nursing which sometimes parallels certain aspects of medicine (i.e. prescribing) just like physicians' care sometimes parallels that of nursing practice (i.e. counseling, education, caring, etc). Nursing and medicine are two separate disciplines where practice components do overlap.
It is beyond me why some feel that one discipline (nursing) needs supervision by a separate discipline (medicine). It is unclear why most do not see this as nothing more than a stronger (yet growing weaker) professions attempt to control a weaker (and growing stronger) profession.
Remember, we as nurses are not in the medical field-we belong to nursing which is the field of health care.
Specializes in ER and family advanced nursing practice.
The issue is that of competency, professional development, autonomy and ultimately accountability. Is a nurse practitioner competent to provide primary care? If not this is an education and training issue. Does being competent include knowing when to refer a patient to a physician or APN specialist? How does this competency differ from that of a physician, and her ability to recognize the need to refer and the fact that there are no supervision requirements in place for primary care physicians? Why does an NP who is deemed compentent in the provision of primary care need supervision over NP practice--especially by someone outside of nursing? .
I am not even sure where to start with this. Are you asking why someone who has been through four years of undergraduate classes, has taken such course work as biology, general chem, organic chem, and physics, and then proceeded to take four years of medical school followed by somewhere in the neighborhood of 8,000 to 12,000 hours of direct patient, hands-on full time clinical training. Are you asking why someone with that background might have some oversight over someone who has four years of BSN training where in some programs only chemistry with an "organic component", a statistics class and around 1000 hours clinical time is required. This is followed by two year of graduate level training with somewhere in the neighborhood of 800 hours taken. That is a total of 1800 (or less). Total.
I know plenty of doctors, and I know plenty of NPs and PAs. Sorry, of the three groups, physicians are WAY more qualified and competent when it comes to primary care. Do I think that a mid level provider with some time under their belt will make an excellent primary care provider. You bet. I hope to become one. But what about a physician with a few years under their belt? You ask why does an NP need supervision by a physician, I ask why would an NP turn down that kind of guidance? Does that improve patient care? Of all the NPs I have worked with and observed it goes something like this: as the physician (and rest of the staff for that matter) becomes more familiar and more comfortable with the NP the less "supervision" that NP gets.
Physicians are licensed to practice medicine. Nurse practitioners are not licensed to practice medicine. Nurse practitioners are licensed by Boards of Nursing. Nurse practitioners are afforded the opportunity to practice advanced nursing which sometimes parallels certain aspects of medicine (i.e. prescribing) just like physicians' care sometimes parallels that of nursing practice (i.e. counseling, education, caring, etc). Nursing and medicine are two separate disciplines where practice components do overlap.
Ummm when you say there are parallels between advance practice nursing and medicine, I would have to say yes, and they are certainly not limited to prescribing medications. First of all before you prescribe you have to do what? Diagnose, and not with NANDA nursing diagnoses, but honest to goodness medical diagnoses. Before you diagnose you have to do what? Assessments, exams, labs, interpretation of of all subjective and objective data including EKGs, labs, X-rays, etc. Sounds awfully medical to me. And what is this business that counseling, education, and caring belongs to nursing? That is just arrogance. I know plenty of doctors that are very interested in those very things. In fact, every day I work in the ICU, I see very kind, caring doctors who educate and counsel not only the patients and their families, but also take time to educate the staff.
It is beyond me why some feel that one discipline (nursing) needs supervision by a separate discipline (medicine). It is unclear why most do not see this as nothing more than a stronger (yet growing weaker) professions attempt to control a weaker (and growing stronger) profession.
Remember, we as nurses are not in the medical field-we belong to nursing which is the field of health care.
You can call it what you want. Advance nursing practice is way more "medical" than it is nursing. I also work with many CRNAs, and I see quite a bit of medicine there, too. Nurses that work with patients work under the supervision of a physician. Why do you think they are called "orders"? They certainly aren't "requests". We have some autonomy and the ability to use critical thinking/judgment in the execution of those orders, but they are still orders. I would love to see any nurse tell one of the surgeons I work with "I am not doing those orders, you're not the boss of me".
Please, I am so tired of the nursing chip on the shoulder. You have a boss. Get over it. I have a boss too. It doesn't belittle me to follow orders or to be supervised by a physician or anyone else for that matter. It certainly doesn't mean I am not competent.
The issue is that of competency, professional development, autonomy and ultimately accountability. Is a nurse practitioner competent to provide primary care? If not this is an education and training issue. Does being competent include knowing when to refer a patient to a physician or APN specialist? How does this competency differ from that of a physician, and her ability to recognize the need to refer and the fact that there are no supervision requirements in place for primary care physicians? Why does an NP who is deemed compentent in the provision of primary care need supervision over NP practice--especially by someone outside of nursing?
Has any NP reading this graduated from an NP program where the terminal objective reads,
"The NP graduate will be competent to provide primary health care services for clients and families across the life cycle with acute and chronic disease, but only with proper supervision from someone outside of the nursing profession."
Physicians are licensed to practice medicine. Nurse practitioners are not licensed to practice medicine. Nurse practitioners are licensed by Boards of Nursing. Nurse practitioners are afforded the opportunity to practice advanced nursing which sometimes parallels certain aspects of medicine (i.e. prescribing) just like physicians' care sometimes parallels that of nursing practice (i.e. counseling, education, caring, etc). Nursing and medicine are two separate disciplines where practice components do overlap.
It is beyond me why some feel that one discipline (nursing) needs supervision by a separate discipline (medicine). It is unclear why most do not see this as nothing more than a stronger (yet growing weaker) professions attempt to control a weaker (and growing stronger) profession.
Remember, we as nurses are not in the medical field-we belong to nursing which is the field of health care.
You obviously aren't an advanced nurse practitioner. People can call it what they want, but we make MEDICAL diagnoses and not nursing diagnoses. NP's have more in common with medicine than they do nursing. A new NP is NOT at the same level as a new MD, it's that simple.
Any NP who gets out of school thinking they are ready to assume full independence has a few screws loose. What you don't know should really scare you.
I am not even sure where to start with this. Are you asking why someone who has been through four years of undergraduate classes, has taken such course work as biology, general chem, organic chem, and physics, and then proceeded to take four years of medical school followed by somewhere in the neighborhood of 8,000 to 12,000 hours of direct patient, hands-on full time clinical training. Are you asking why someone with that background might have some oversight over someone who has four years of BSN training where in some programs only chemistry with an "organic component", a statistics class and around 1000 hours clinical time is required. This is followed by two year of graduate level training with somewhere in the neighborhood of 800 hours taken. That is a total of 1800 (or less). Total.
I'm not sure what your point is here. Physicians practice medicine and nurses, even advance practice nurses, practice nursing(please inform me if you are aware of any medical board in the country that licenses nurse practitioners.) This includes diagnosing and prescribing disease. Nurses belong to the discipline of nursing and physicians belong to the discipline of medicine. Physicians are licensed by medical boards who dictate scope of practice for medicine and advance practice nurses are licensed by boards of nursing who prescribe scope of practice for nursing.
I know plenty of doctors, and I know plenty of NPs and PAs. Sorry, of the three groups, physicians are WAY more qualified and competent when it comes to primary care.
I disagree with your use of the concept, "competent." I feel that the concept "competence" is not the same as "expertise". I feel that one either, is, or is not competent to perform a function, practice or task. I do not feel there are varying degrees of competence any more than there are varying degrees of death. One is either dead or not. One is either competent or not. In the present, one is either competent to provide primary health care services or not. Expertise, however, permits varying degrees that are based on experience, education and training and to that end, I would agree that medical-model based physician training programs carry more hours in education and training that PA or NP training programs. I would not agree, however, that all physicians' posses more expertise over NP's, as this would be a generalization that is not appropriate and is not based on reality. For more information related to this, please review Patricia Benner's Expert to Novice schema and think about the construct of primary care.
Do I think that a mid level provider with some time under their belt will make an excellent primary care provider. You bet. I hope to become one. But what about a physician with a few years under their belt? You ask why does an NP need supervision by a physician, I ask why would an NP turn down that kind of guidance? Does that improve patient care? Of all the NPs I have worked with and observed it goes something like this: as the physician (and rest of the staff for that matter) becomes more familiar and more comfortable with the NP the less "supervision" that NP gets.
Again, the issue is that of competence. A NP is either competent to provide primary health care services or not. The provision of primary care services is an independent function by NP's in 23 states without any need for physician supervision or oversight. A physician is either competent to provide primary care services or not. There is no such animal as "being more competent." Supervision of one discipline by another in the context of differing models of care (ie. Medical model versus nursing process) is as inappropriate and ridiculous as the need for dentists, chiropractors, optometrists, pharmacists and other clinical-based disciplines to be supervised by physicians. Again, in the context of health care service delivery, one is either competent or not.
Ummm when you say there are parallels between advance practice nursing and medicine, I would have to say yes, and they are certainly not limited to prescribing medications. First of all before you prescribe you have to do what? Diagnose, and not with NANDA nursing diagnoses, but honest to goodness medical diagnoses. Before you diagnose you have to do what? Assessments, exams, labs, interpretation of of all subjective and objective data including EKGs, labs, X-rays, etc. Sounds awfully medical to me. And what is this business that counseling, education, and caring belongs to nursing? That is just arrogance. I know plenty of doctors that are very interested in those very things. In fact, every day I work in the ICU, I see very kind, caring doctors who educate and counsel not only the patients and their families, but also take time to educate the staff.
You are correct in saying that functions of APN's and physicians do indeed overlap, and those functions do not belong to any one discipline, just like prescribing antibiotics by a dentist is not considered the practice of medicine, but the practice of dentistry. It is important for you to understand this, because this remains the number one barrier for ANP advancement in the context of independent practice. Anti ANP movement organizations such as the AMA, CMA and other professional medical-based societies would have all believing that these functions are "medical" as you incorrectly state, because they say so. For example, you state that diagnosis comes before treatment, which is correct. However, you are misinformed to think that diagnosis in the context you are using are or belong exclusively to the medical discipline. I presume you are referring to the ICD-9 coding schema. You will note that the term Nursing, Medicine, Dentistry, Optometry or any other clinical-based discipline and profession are conspicuously absent within the codification of "International Statistical Classification of Diseases and Related Health Problems."
Your notation that physicians do engage in counseling and education that underpins the concept of arrogance to think that physicians do not do this on a daily basis is correct and underscores my point that functions of a practitioner do not belong to any one profession or discipline. Again, just because the nursing practice act includes counseling and education for clients and families does not mean that when physicians perform this function that this function is nursing. When a physician provides counseling and education it is the practice of medicine; when a nurse provides same, it is the practice of nursing; when a dentist provides the same, it is the practice of dentistry.
You can call it what you want. Advance nursing practice is way more "medical" than it is nursing. I also work with many CRNAs, and I see quite a bit of medicine there, too. Nurses that work with patients work under the supervision of a physician. Why do you think they are called "orders"? They certainly aren't "requests". We have some autonomy and the ability to use critical thinking/judgment in the execution of those orders, but they are still orders. I would love to see any nurse tell one of the surgeons I work with "I am not doing those orders, you're not the boss of me".
Again, by calling advance practice nursing functions a task within another discipline underpins the argument that APN's are practicing medicine, which consequently would require medical supervision, just like paramedics need a medical director because paramedics practice medicine under the auspices of a county, regional or state medical director under medical director approved protocols. This is incorrect and inappropriate in nursing, however, in that APN's are not licensed to practice medicine and the nursing model is not the same as the medical model, which informs, directs and guides care.
Please, I am so tired of the nursing chip on the shoulder. You have a boss. Get over it. I have a boss too. It doesn't belittle me to follow orders or to be supervised by a physician or anyone else for that matter. It certainly doesn't mean I am not competent.
As far as having a boss, and the need for supervision, one thing has nothing to do with the other. As far as getting over something, perhaps you may decide on a different field that will attempt to dominate and control a different one. Perhaps you will concede that nursing must be supervised by medicine and be a staunch ally of medical model based organizations that continue to this day in attempting to stymie professional growth and development of APN's, which ultimately will have a negative relationship to consumers access to cost effective and high quality primary health care. To that end, I don't know what to tell you.
As far as me, I will continue to point out these differences; attempt to educate those inside and outside the profession and be a zealous advocate for both by clients and the profession for which I have chosen.
You obviously aren't an advanced nurse practitioner. People can call it what they want, but we make MEDICAL diagnoses and not nursing diagnoses. NP's have more in common with medicine than they do nursing. A new NP is NOT at the same level as a new MD, it's that simple.
No, not a nurse practitioner yet, but I'm sorry you feel this way. By indicating advance nursing practice is guided more by the discipline of medicine and not nursing only serves to disintegrate the identity of nursing in the context of advance nursing practice and underpins the argument by medical-based professional associations that medicine is the only logical supervising entity. This was the argument that was used, as an example, by the CMA to destroy a scope of practice bill for NP's in California. Consequently, the more we subscribe to this system of beliefs, the more control we will surrender nursing control and movement to medicine in what we are able and not able to do. Essentially, our paths and fate will be dictated by a profession other than nursing. Thank goodness not all feel this way, as the 23 states who provide for NP independent practice would surely give way to dependent practice dictated exclusively by medicine.
Back in undergraduate 20 some years ago, I remember one of my professors saying that nurses are their own worst enemy when it comes to professional development in the context of practice advancement. I hope for the sake of nursing and consumers access to quality and affordable care that these notions related to professional identity disintegration will fade and be replaced by those who value nursing and nursing's contribution to the provision of primary health care services. As Lewin identified as barriers to change which is supported by Everett Rogers posits of diffusion, I hope that one day, we can all agree that we are nurses in the context of primary care and not junior doctors who quite aren't physicians. In the absence of this occurrence, all NP's will be relegated to tasks dictated by another profession and we had better get use to the idea of being paraprofessionals.
Any NP who gets out of school thinking they are ready to assume full independence has a few screws loose. What you don't know should really scare you.
I don't know any practicing NP or MD who assumes full independence, nor is this the issue. The issue is that of supervision; which, if any, discipline should supervise nursing and the competence by APN's to provide primary care health services.
Specializes in ER and family advanced nursing practice.
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. Physicians practice medicine and nurses, even advance practice nurses, practice nursing(please inform me if you are aware of any medical board in the country that licenses nurse practitioners.) This includes diagnosing and prescribing disease. Nurses belong to the discipline of nursing and physicians belong to the discipline of medicine. Physicians are licensed by medical boards who dictate scope of practice for medicine and advance practice nurses are licensed by boards of nursing who prescribe scope of practice for nursing.
Doesn’t matter if medical boards license advanced nurses or not. They have a major impact and influence over the scope of advanced nursing practice. You can call the practice of advanced practice nursing whatever you want. I will not get drawn into a quibble over nomenclature. That is just silly. What matters is the actual action or practice, and there is very little “nursing” practice in advance nursing. Tell me one such action that is “nursing” in the practice of an FNP. If it makes you feel better about calling it nursing then call it that.
I disagree with your use of the concept, "competent." I feel that the concept "competence" is not the same as "expertise". I feel that one either, is, or is not competent to perform a function, practice or task. I do not feel there are varying degrees of competence any more than there are varying degrees of death. One is either dead or not. One is either competent or not. I would agree that medical-model based physician training programs carry more hours in education and training that PA or NP training programs. I would not agree, however, that all physicians' posses more expertise over NP's, as this would be a generalization that is not appropriate and is not based on reality.
Of course there are varying degrees of competence, and for that matter as an ICU nurse I will tell you that there are most definitely different shades of death. I do agree that expertise and competence are not the same but they are related. If you want to suggest that competence is the minimum standard of capable functioning along the continuum of expertise, I would concede that to you, but if you want to hang a shingle that says “J. Smith FNP, I meet minimum standards” please be my guest.
I did not say that “all” physicians have more expertise than NPs, I too have worked with some scary people in all fields, but guess what? Physicians are vastly more like to have more expertise and yes more competence than an FNP/PA.
Supervision of one discipline by another in the context of differing models of care (ie. Medical model versus nursing process) is as inappropriate and ridiculous as the need for dentists, chiropractors, optometrists, pharmacists and other clinical-based disciplines to be supervised by physicians.
You are correct in saying that functions of APN's and physicians do indeed overlap, and those functions do not belong to any one discipline, just like prescribing antibiotics by a dentist is not considered the practice of medicine, but the practice of dentistry. It is important for you to understand this, because this remains the number one barrier for ANP advancement in the context of independent practice. Anti ANP movement organizations such as the AMA, CMA and other professional medical-based societies would have all believing that these functions are "medical" as you incorrectly state, because they say so. For example, you state that diagnosis comes before treatment, which is correct. However, you are misinformed to think that diagnosis in the context you are using are or belong exclusively to the medical discipline. I presume you are referring to the ICD-9 coding schema.
What??? If dentists and chiropractors ventured into the realm of primary care, I imagine the AMA would have something to say about that. That analogy doesn’t work. And what is up with the nursing process reference? A group of “theorist” gets together and names the same problem solving technique used by all kinds of different professions and now it belongs to nursing? Plumbers, mechanics, and electricians use the exact same process. Please tell me how the medical evaluation is different. What’s that you say? More overlap? Hmmm…..
I am confused about your diagnosing/ICD-9 thing. Is the provider naming/diagnosing the disease or not? If so, that is different from “nursing” diagnosis. Were you not saying that medical is medical and nursing is nursing? Or is this yet more overlap? You can’t stand on the political soap box and tell the world “We are different; we just do everything the same.” No one has demonstrated to me that advanced practice “nursing” or whatever you want to call it is any different from physicians do except our scope is not as broad or deep.
Your notation that physicians do engage in counseling and education that underpins the concept of arrogance to think that physicians do not do this on a daily basis is correct and underscores my point that functions of a practitioner do not belong to any one profession or discipline. Again, just because the nursing practice act includes counseling and education for clients and families does not mean that when physicians perform this function that this function is nursing. When a physician provides counseling and education it is the practice of medicine; when a nurse provides same, it is the practice of nursing; when a dentist provides the same, it is the practice of dentistry.
Here again you seemed awfully concerned with process of nomenclature and not function and action. This has been addressed and readdressed. Call it what you like. That doesn’t change what something is. Call it the practice of lolly lolly if you want. If you giving the same information, caring, and counseling to the patient as an advanced practice nurse that a physician would then you are doing the same thing. You seem fixated on dentistry. You are again just pointing that it might be called something different, but the action is the same. This illustrates the major problem that nursing has: nursing sits, spins its wheels and worries about superficial areas of concern like what something is called as opposed to what it does.
Again, by calling advance practice nursing functions a task within another discipline underpins the argument that APN's are practicing medicine, which consequently would require medical supervision, just like paramedics need a medical director because paramedics practice medicine under the auspices of a county, regional or state medical director under medical director approved protocols. This is incorrect and inappropriate in nursing, however, in that APN's are not licensed to practice medicine and the nursing model is not the same as the medical model, which informs, directs and guides care.
Wait…If nurses practice nursing, and doctors practice medicine, then how can paramedics practice anything but paramedic practice. Right? That is what you are saying. Different profession, they must have a different practice right? So why should physicians have supervision or medical control over paramedics? I have a paramedic license, and it is not under the medical board of licensing. Yet physicians determine my protocols and what I can do and not do. Shall I tell them to stop because they have a different profession and couldn’t possibly have anything to do with what I do? This is why your entire argument doesn’t work. You are not alone with your opinion. In fact, I am very likely in the minority on this one, but again, I am not going feel outraged over issues like what something is called or that a profession that has much deeper training, knowledge, and yes, expertise might have oversight over my daily practice. I am here to be part of a team. Period.
Doesn't matter if medical boards license advanced nurses or not.
Really? Would you prefer and be more comfortable if medical boards licensed NP's? Would that make you more comfortable with the idea that medicine is truly attempting to dictate nursing and advance practice nursing's future?
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They have a major impact and influence over the scope of advanced nursing practice. You can call the practice of advanced practice nursing whatever you want. I will not get drawn into a quibble over nomenclature. That is just silly.
I agree, that professional medical associations continue to try to influence the scope of advance nursing practice. The, quibbling, as you say actually is a bit more than academic. If we concede that what APN's do is the practice of medicine, then we as nurses need to get comfortable with being paraprofessionals of medicine, like paramedics are, and not nurses.
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What matters is the actual action or practice, and there is very little "nursing" practice in advance nursing. Tell me one such action that is "nursing" in the practice of an FNP. If it makes you feel better about calling it nursing then call it that.
Just one? Here are a few texts that will outline thousands upon thousands of nursing actions in the context of advance nursing practice. Please let me know if you need more examples.
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2007). Primary care: the art and science of advanced practice nursing (2nd ed.). Philadelphia: F.A. Davis Co.
Edmunds, M.W. & Mayhew, M.S. (2003). Procedures for primary care practitioners (2nd ed.). St. Louis: Mosby.
Fenstermacher and Hudson (2004). Practice Guidelines for Family Nurse Practitioners (3rd ed.). Saunders (Elsevier), Philadelphia.
Kennedy-Malone, L.D., Fletcher, K.R., & Plank, L.M. (2004). Management guidelines for nurse practitioners working with older adults. (2nd ed.). Philadelphia: F.A. Davis.
Richardson, B. (2005). Practice guidelines for pediatric nurse practitioners. St. Louis: Elsevier: Mosby.
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I do agree that expertise and competence are not the same but they are related.
Good for you! An astute observation.
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I did not say that "all" physicians have more expertise than NPs, I too have worked with some scary people in all fields, but guess what? Physicians are vastly more like to have more expertise and yes more competence than an FNP/PA.
I've been looking for such research that demonstrates levels of expertise between NP's and physicians. Could you please provide a reference?
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What??? If dentists and chiropractors ventured into the realm of primary care, I imagine the AMA would have something to say about that. That analogy doesn't work. And what is up with the nursing process reference? A group of "theorist" gets together and names the same problem solving technique used by all kinds of different professions and now it belongs to nursing? Plumbers, mechanics, and electricians use the exact same process.
Again, you have clearly missed the point. Physicians have no business regulating or controlling other disciplines such as dentistry, chiropractic, optometry, or nursing. NP's are deemed clinically competent to provide primary health care services. Please let me no if you can reference any citation indicating the contrary. And lest we forget, the nursing process is the process we use as nurses, regardless of basic or advance nursing. Here in California this is made clear in the nursing practice act. A competent nurse is a nurse who uses the nursing process. Remember, a NP is a nurse, just like a paramedic is an EMT. Just because you become a paramedic doesn't mean we forget about BLS or were not accountable to basic provisions of care as that of a basic EMT.
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Please tell me how the medical evaluation is different. What's that you say? More overlap? Hmmm.....I am confused about your diagnosing/ICD-9 thing. Is the provider naming/diagnosing the disease or not? If so, that is different from "nursing" diagnosis. Were you not saying that medical is medical and nursing is nursing? Or is this yet more overlap? You can't stand on the political soap box and tell the world "We are different; we just do everything the same." No one has demonstrated to me that advanced practice "nursing" or whatever you want to call it is any different from physicians do except our scope is not as broad or deep.
It's beyond me or my time to remediate you on the differences between an actual or potential response to a health condition versus an actual or possible disease entity. For this, please revisit some remedial nursing texts related to nursing diagnosis versus diagnosing a disease entity. NP's diagnose disease. NP's use the codification schema, in part, within the ICD-9. The point here is that ICD-9 CONTAINS NO mention of medical practice or the excusive utility of ICD-9 as a basis for medical practice. ICD-9 codes are used by many different disciplines such as medicine, advance practice nursing, optometry and yes, dentistry.
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Here again you seemed awfully concerned with process of nomenclature and not function and action. This has been addressed and readdressed. Call it what you like. That doesn't change what something is. Call it the practice of lolly lolly if you want.
Thank you, and I will call it nursing when a NP provides assessment and treatment and medicine when a physician performs the same function. I am uncomfortable with practicing within a discipline in which I'm not licensed. Here in California, it's actually a misdemeanor to practice medicine without a license.
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Wait...If nurses practice nursing, and doctors practice medicine, then how can paramedics practice anything but paramedic practice. Right? That is what you are saying. Different profession, they must have a different practice right? So why should physicians have supervision or medical control over paramedics? I have a paramedic license, and it is not under the medical board of licensing. Yet physicians determine my protocols and what I can do and not do. Shall I tell them to stop because they have a different profession and couldn't possibly have anything to do with what I do? This is why your entire argument doesn't work. You are not alone with your opinion. In fact, I am very likely in the minority on this one, but again, I am not going feel outraged over issues like what something is called or that a profession that has much deeper training, knowledge, and yes, expertise might have oversight over my daily practice. I am here to be part of a team. Period.
I was hoping you would bring this up as this points directly to the issue at hand. As a paramedic educator, it is quite difficult to explain to my students the difference between a paraprofessional and a professional as these are abstract terms with subtle nuances. I explain to them, as I will explain to you, that paramedics are certificated and licensed under the provisions of practicing under that of a medical director. Please let me know if you know of any state where paramedics do not work under such a framework--that is they work without the authority of a physician medical director.
I also explain that the term "medical" is deeply embedded with the title and consequently, dictates their practice. This is included in the very name, "Emergency MEDICAL technician-paraMEDIC. Paramedics are not allowed to operate within their scope of practice without a medical director, which is always a physician. This is different than that of a nurse, and in 23 states, NP's. Nurses have their own scope of practice which delineates their scope. This is why nurses, as an example in California, may work anywhere and why paramedics in California, may only work in areas in which they are accredited--accredited by the local agency medical director. In California, paramedics are licensed, but only to the extent of their respective accreditation status within a geographical area. Nurses, because it is a separate discipline and profession are not confined to these barriers to practice.
Perhaps you are comfortable with a similar relationship occurring with NP's. I however am not, which is why I will continue to educate those within the profession that nursing is separate and its own discipline, apart from that of medicine. As a paramedic, I understand that I am a paraprofessional in which I have little input over the direction of my scope of practice. As a nurse, I understand that I am within a separate discipline, which collectively we as nurses are empowered to dictate our own direction.
As a paramedic, I have limited power to do battle with medical control over paramedicine, as this is controlled exclusively by the medical director. As a nurse, I have absolute power to rally with other nurses to give meaning to who we are, where we are going, and the level of scope of practice in which we provide nursing care for our clients.
Specializes in ER and family advanced nursing practice.
Really? Would you prefer and be more comfortable if medical boards licensed NP's? Would that make you more comfortable with the idea that medicine is truly attempting to dictate nursing and advance practice nursing's future?
I wouldn’t care one way or the other, I did not get into this profession because of who did or did not license NPs. I got into this profession because I enjoy helping people and making a difference in my small sphere of influence. I work hard and try to set a good example for my child. What do I care were my license comes from? It’s more of the same: those evil doctors! Trying to stop us from practicing. We are not practicing medicine, we are practicing nursing!
Its old and it’s a cliché.
I agree, that professional medical associations continue to try to influence the scope of advance nursing practice. The, quibbling, as you say actually is a bit more than academic. If we concede that what APN's do is the practice of medicine, then we as nurses need to get comfortable with being paraprofessionals of medicine, like paramedics are, and not nurses.
I take offense to that. Long before I was nurse I was a paramedic. Even then I was a professional from day one. So don’t you dare tell me otherwise. I am a professional. Paramedics are every bit a part of a profession as nursing. Yes I know the “list” of what it takes to be profession. It carries no weight with me. If people up in the ivory tower want say otherwise then that is on them. I am a professional as a paramedic and as a nurse. For the record, nurses have not fully met those requirements either. But again, I am in the profession of nursing.
Just one? Here are a few texts that will outline thousands upon thousands of nursing actions in the context of advance nursing practice. Please let me know if you need more examples.
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2007). Primary care: the art and science of advanced practice nursing (2nd ed.). Philadelphia: F.A. Davis Co.
Edmunds, M.W. & Mayhew, M.S. (2003). Procedures for primary care practitioners (2nd ed.). St. Louis: Mosby.
Fenstermacher and Hudson (2004). Practice Guidelines for Family Nurse Practitioners (3rd ed.). Saunders (Elsevier), Philadelphia.
Kennedy-Malone, L.D., Fletcher, K.R., & Plank, L.M. (2004). Management guidelines for nurse practitioners working with older adults. (2nd ed.). Philadelphia: F.A. Davis.
Richardson, B. (2005). Practice guidelines for pediatric nurse practitioners. St. Louis: Elsevier: Mosby.
Sweet. These are all NP text that are full of primary care procedures. I give you that, but the question still stands. Show me one of those procedures that is strictly done by NPs, and not also PAs (back to the OP) or physicians. Your list, while impressive, is not a response.
I've been looking for such research that demonstrates levels of expertise between NP's and physicians. Could you please provide a reference?
No. Because one has never been done. Why should there be? There is no question to that outcome in the big picture. Sure there are exceptions, but they are exceptions and I am sure they are few. Maybe this is the part where you are going to tell me you would go toe to toe with an MD and tell them of your greater expertise.
What would be a more valid study would be to look for the difference in outcomes in the comparison of patients that are treated by NPs vs PAs vs MDs. There are several studies and all are very favorable in that the NPs outcomes are at least as good the MD. My response to that fact would be, “And your point is?” How many of those NPs were dependent/independent? How many received training from MDs? If they didn't what about their preceptors? Were they trained by MDs. Somewhere in your training a physician has been involved. Either at school, or on the job. I agree NPs have a lot of success and many reasons to be proud, but that doesn’t change the fact they are using medical approaches. Maybe those docs trained us too well.
It's beyond me or my time to remediate you on the differences between an actual or potential response to a health condition versus an actual or possible disease entity. For this, please revisit some remedial nursing texts related to nursing diagnosis versus diagnosing a disease entity. NP's diagnose disease. NP's use the codification schema, in part, within the ICD-9. The point here is that ICD-9 CONTAINS NO mention of medical practice or the excusive utility of ICD-9 as a basis for medical practice. ICD-9 codes are used by many different disciplines such as medicine, advance practice nursing, optometry and yes, dentistry.
Excuse me? I do not need to be re-mediated. I understand perfectly what a nursing diagnosis is. It is just funny I don’t see advanced practice nurses using them. At no time in my clinicals or my experience of working with NPs (following their medical orders as a bedside ICU nurse) have I ever seen an APN use a NANDA nursing dx. Not one chart, ever. Doesn’t mean they don’t. I just have not seen it, and I have worked quite a bit with NPs. Now that you mention it. I don't remember the last I saw a bedside RN use a nursing dx.
Thank you, and I will call it nursing when a NP provides assessment and treatment and medicine when a physician performs the same function. I am uncomfortable with practicing within a discipline in which I'm not licensed. Here in California, it's actually a misdemeanor to practice medicine without a license.
In effect you are saying that even though the action is the same (that is what you just posted) that it is different (and thereby legal in California) only because you have named it something different, even though you are doing the same thing. Interesting laws you have in California. Very interesting.
I was hoping you would bring this up as this points directly to the issue at hand. As a paramedic educator, it is quite difficult to explain to my students the difference between a paraprofessional and a professional as these are abstract terms with subtle nuances. I explain to them, as I will explain to you, that paramedics are certificated and licensed under the provisions of practicing under that of a medical director. Please let me know if you know of any state where paramedics do not work under such a framework--that is they work without the authority of a physician medical director.
If it is so abstract and so subtle then why do you tell your students they are not professionals. That is pretty lame. I too am a paramedic educator. I tell my students they are professionals. Guess I am one of those “glass half full guys”.
I am glad you were hoping I would bring that up, but you still didn’t answer the question: according to you they are a different professions (EMT vs MD), different licensing agencies, so why should MDs have any say in EMT practice?
Many paramedics don’t work under a physician’s license. There are states that use EMTs and paramedics in the hospital as techs with varying amounts of responsibility. I worked in an ER in Colorado. I could give meds, start IVs, place NGs, OGs, start protocols, and guess what? Not under the license of a physician.
I agree, EMTs operate under the medical model, yet they are clearly not doctors. How can that be? I mean other than they have the word medical in their title.
Perhaps you are comfortable with a similar relationship occurring with NP's. I however am not, which is why I will continue to educate those within the profession that nursing is separate and its own discipline, apart from that of medicine. As a paramedic, I understand that I am a paraprofessional in which I have little input over the direction of my scope of practice. As a nurse, I understand that I am within a separate discipline, which collectively we as nurses are empowered to dictate our own direction.
I would be comfortable, why wouldn’t I be? I am just wondering who you think trains NPs? Is it ever doctors? But how can a doctor train an NP if the NP doesn't use the medical model and the doctor clearly doesn't use the nursing model. Who did a large majority of the initial training for NPs back in the day, you know, before there were NPs? Probably doctors.
Why as a paramedic do you have so little input over the scope of your practice? I have seen paramedics speak up and make all kinds of things happen. Including the expansion of protocols. Sorry California is so hard on you guys. The fact that you have resigned yourself to only being an “almost” professional paramedic might have something to do with that. Of course another part of it might be the powerful California nursing unions not letting paramedics practice in the hospital using their skills even though, and you might like this, there are no studies that have demonstrated worse outcomes if paramedics are allowed to use their skills inside a hospital (and they do in some states). Interesting that nursing wouldn't allow another profession encroach on their territory.
As a paramedic, I have limited power to do battle with medical control over paramedicine, as this is controlled exclusively by the medical director. As a nurse, I have absolute power to rally with other nurses to give meaning to who we are, where we are going, and the level of scope of practice in which we provide nursing care for our clients.
And that is it right there “Battle”. That is your approach. Battle, to arms, lay siege and all that good stuff. I don’t need other nurses to have absolute power to give meaning to who I am. That kind of meaning comes from within. Maybe that’s something for you to look at.
Look, I agree. As a nurse, I can only nurse. I can’t “doctor”. I get that. But like advocacy and caring doesn’t belong to nursing. The medical model no longer belongs strictly to physicians. It once did, but not now. MDs might not like that, but we are here to stay. Advanced nurses collectively have taken a small part of the medical model and demonstrated excellence. I will say this: I will be an advanced practice nurse operating under the medical model. That is my choice.
I wouldn't care one way or the other, I did not get into this profession because of who did or did not license NPs. I got into this profession because I enjoy helping people and making a difference in my small sphere of influence. I work hard and try to set a good example for my child. What do I care were my license comes from? It's more of the same: those evil doctors! Trying to stop us from practicing. We are not practicing medicine, we are practicing nursing!
Its old and it's a cliché.
Which profession is that? Nursing, or a subcomponent of medicine? With that line of thinking, why did you not choose medical school or stay a paramedic? Can you not help people as a physician or paramedic? Did your APN program really not cover systems integration, nursing theory, process oriented practice nursing models? Is this really so foreign of a construct to grasp that, physician opposition notwithstanding, we are really nurses?
I take offense to that. Long before I was nurse I was a paramedic. Even then I was a professional from day one. So don't you dare tell me otherwise. I am a professional. Paramedics are every bit a part of a profession as nursing. Yes I know the "list" of what it takes to be profession. It carries no weight with me. If people up in the ivory tower want say otherwise then that is on them. I am a professional as a paramedic and as a nurse. For the record, nurses have not fully met those requirements either. But again, I am in the profession of nursing.
Please read my original statement and try not to bend what I am saying. Also, do some research on the components of the requisite elements of a profession and please be able to distinguish this from the concepts of professionalism and professional.
Sweet. These are all NP text that are full of primary care procedures. I give you that, but the question still stands. Show me one of those procedures that is strictly done by NPs, and not also PAs (back to the OP) or physicians. Your list, while impressive, is not a response.
I believe your following post requested:
Tell me one such action that is "nursing" in the practice of an FNP
I was only trying to help you find some. Now you have thousands. Now you are changing the question, which incidentally makes my point once again. These are not functions exclusive to FNP's, except in the context that NP's performing these functions are practicing advance practice nursing and not medicine. Again, when doctors, to use your term which I will presume you mean physicians and not a DNPs, perform these functions, it is again the practice of medicine. Again, thanks for making my point.
No. Because one has never been done. Why should there be? There is no question to that outcome in the big picture. Sure there are exceptions, but they are exceptions and I am sure they are few. Maybe this is the part where you are going to tell me you would go toe to toe with an MD and tell them of your greater expertise.
What would be a more valid study would be to look for the difference in outcomes in the comparison of patients that are treated by NPs vs PAs vs MDs. There are several studies and all are very favorable in that the NPs outcomes are at least as good the MD. My response to that fact would be, "And your point is?" How many of those NPs were dependent/independent? How many received training from MDs? If they didn't what about their preceptors? Were they trained by MDs. Somewhere in your training a physician has been involved. Either at school, or on the job. I agree NPs have a lot of success and many reasons to be proud, but that doesn't change the fact they are using medical approaches. Maybe those docs trained us too well.
Again, if you want to consider yourself a paraprofessional, that is, you consider advance practice nursing nothing more than a spin off of medicine, and APN's are nothing more than junior physicians and we cannot and should not govern ourselves, our practice and our future, be by guest. You will be more than welcomed by a host of medical-based professional organizations composed of physicians who feel the same way that do nothing but try and move nursing in that direction. Fortunately, most realize that this accomplishes nothing more than our professions' disintegration.
Excuse me? I do not need to be re-mediated. I understand perfectly what a nursing diagnosis is. It is just funny I don't see advanced practice nurses using them. At no time in my clinicals or my experience of working with NPs (following their medical orders as a bedside ICU nurse) have I ever seen an APN use a NANDA nursing dx. Not one chart, ever. Doesn't mean they don't. I just have not seen it, and I have worked quite a bit with NPs. Now that you mention it. I don't remember the last I saw a bedside RN use a nursing dx.
Good work! Now the next part of the mission is for you to point out where the term "physician", "medical" or anything of the like is imbedded with the ICD-9 schema that indicates that by utility of such codes comprises the practice of medicine. Let me know if you find.
In effect you are saying that even though the action is the same (that is what you just posted) that it is different (and thereby legal in California) only because you have named it something different, even though you are doing the same thing. Interesting laws you have in California. Very interesting.
Good work, I think you are starting to understand. If a nurse changes a bedpan, it is nursing. If a doctor (physician in this context) does it, it is the practice of medicine, unless the physician also possesses a nursing license to do so. When a physician orders an x-ray, it is the practice of medicine. When a dentist does so it is the practice of dentistry. When a NP orders the x-ray, it is a component of advance nursing practice. If a NP orders an x-ray, and this is considered to be the practice of medicine, which is what the professional medical associations would like to categorize this as, then NP's will be in a paraprofessional category and have no control of our path or future. If you are comfortable with this, that's all good. I, however am not. Unfortunately, it is beyond my capabilities to make it any simpler than that.
If it is so abstract and so subtle then why do you tell your students they are not professionals.
Again, please review the components of a profession, the concept of professionalism and the term professional. Again, please try and not fabricate what I am saying. It's beneath you.
I would be comfortable, why wouldn't I be? I am just wondering who you think trains NPs? Is it ever doctors? But how can a doctor train an NP if the NP doesn't use the medical model and the doctor clearly doesn't use the nursing model. Who did a large majority of the initial training for NPs back in the day, you know, before there were NPs? Probably doctors.
In my NP program we have physicians who provide lectures, just like in medical school they have nurses that provide lectures. Doctors did teach the original NP programs. Dr. Loretta Ford, the first NP in the country, a good friend of mine, was one of the educators. I'm not sure really what your point is. Perhaps you are confusing this with the first PA program, which was taught exclusively by physicians. Any idea why? Think medical model.
Why as a paramedic do you have so little input over the scope of your practice? I have seen paramedics speak up and make all kinds of things happen. Including the expansion of protocols. Sorry California is so hard on you guys. The fact that you have resigned yourself to only being an "almost" professional paramedic might have something to do with that. Of course another part of it might be the powerful nursing unions not letting paramedics practice in the hospital using their skills even though, and you might like this, there are no studies that have demonstrated worse outcome if paramedics are allowed to use their skills inside a hospital (and they do in some states). Interesting that nursing wouldn't allow another profession encroach on their territory.
Again, please let me know one state in the country where paramedics may practice independent of a medical director--just one. Again, reconcile this with your homework on investigating the components necessary to make a profession.
Look, I agree. As a nurse, I can only nurse. I can't "doctor". I get that. But like advocacy and caring doesn't belong to nursing. The medical model no longer belongs strictly to physicians. It once did, but not now. MDs might not like that, but we are here to stay. Advanced nurses collectively have taken a small part of the medical model and demonstrated excellence. I will say this: I will be an advanced practice nurse operating under the medical model. That is my choice.
Again, it is your prerogative to think advance practice nurses are spin offs of the medical model and NP's are nothing more than my favorite term "mid level providers" or even better, "physician extenders." With this line of thinking and using this to guide practice for NP's does nothing but underpin the medical professional associations arguments that we need medical-based supervision and underscores our status as paraprofessionals in that we are operating in another discipline in which we are not trained, socialized or licensed. But then again, 50 years ago nurses truly believed that chairs belonged to physicians on the nursing unit, which is why nurses would have to give their seat up whenever a physician walked on the unit. As I said before, together nurses can accomplish almost anything, but often act as their own worst enemy with regards to professional identity and practice development.
I can't believe I actually just read all of these recent posts! Tammy wins on many well described points, although she will be more effective with less demeaning comments. I suspect Tammy and ivan's future NP professors are in for a treat, so much passion will spark great debates. I personally feel both will be great additions to the NP profession.
Dr. Tammy, FNP/GNP-C
618 Posts
The issue is that of competency, professional development, autonomy and ultimately accountability. Is a nurse practitioner competent to provide primary care? If not this is an education and training issue. Does being competent include knowing when to refer a patient to a physician or APN specialist? How does this competency differ from that of a physician, and her ability to recognize the need to refer and the fact that there are no supervision requirements in place for primary care physicians? Why does an NP who is deemed compentent in the provision of primary care need supervision over NP practice--especially by someone outside of nursing?
Has any NP reading this graduated from an NP program where the terminal objective reads,
"The NP graduate will be competent to provide primary health care services for clients and families across the life cycle with acute and chronic disease, but only with proper supervision from someone outside of the nursing profession."
Physicians are licensed to practice medicine. Nurse practitioners are not licensed to practice medicine. Nurse practitioners are licensed by Boards of Nursing. Nurse practitioners are afforded the opportunity to practice advanced nursing which sometimes parallels certain aspects of medicine (i.e. prescribing) just like physicians' care sometimes parallels that of nursing practice (i.e. counseling, education, caring, etc). Nursing and medicine are two separate disciplines where practice components do overlap.
It is beyond me why some feel that one discipline (nursing) needs supervision by a separate discipline (medicine). It is unclear why most do not see this as nothing more than a stronger (yet growing weaker) professions attempt to control a weaker (and growing stronger) profession.
Remember, we as nurses are not in the medical field-we belong to nursing which is the field of health care.