Do NP's Practice Medicine?

Advanced Practice Columnist / Guide · Jun 18, 2008

It depends on who you ask and where you live. ANCC who certifies some NP specialties and CCNA who certifies CRNA's are specialty boards that are accredited by the National Boards of Nursing Specialties. Technically, the standards set on what minimum level of competency is required via certification is established by a nursing board in this case. One can then assume that the acts performed by NP's in this case, whether they are the same as the ones physicians perform, still fall into a nursing specialty and are thus, within the confines of advanced practice nursing and not medicine.

However, state to state rules vary. There are states where professional practice acts and legislation give the BON the sole responsibility of regulating the practice of NP's. In these states, NP's practice within the confines of nursing in an advanced role achieved by virtue of the NP's advanced training and specialty certification. In some states, both the BON and BOM regulate NP practice. Technically, these states confirm that some acts performed by NP's fall into the practice of medicine, hence, the oversight by the BOM.

In recent developments, the proposed certification exam for DNP's is one that is developed by the American Board of Medical Specialties, a group that represents the medical profession. One can interpret then that this is a validation of the fact that many NP roles fall into the practice of medicine, or at least, the proposed roles a DNP certified NP can perform per the group that is offering this new DNP certification.

As a practicing NP, I have the opinion that a vast majority of the day to day acts I perform in my role fall into the practice of medicine. I have to admit that I do not formally utilize or adhere to a particular nursing theory in my current practice. I know, I admitted it and I could just hear my nursing professors growling in disappointment right about now. However, many of my medical decision-making are highly influenced by my nursing background and knowledge of theories of human responses to illness, stress, and human ability to cope which I learned in nursing school.

Since you asked for a personal opinion, the above is what I can offer as far as your question. Some may agree or disagree.

forpath · Jun 18, 2008

Is prescribing medication, as an example, a function that is exclusive to medicine? When a M.D./D.O. gives a prescription it is well established that this is practicing medicine; when a dentist does the same it is the practice of dentistry.
I know that practicing medicine without a license is a crime. I also know that I can't lend someone else my driver's license so they can drive a car, just like probably an NP can't work under the license of an MD as much as rules specify and call for collaboration in the form of supervision and/or protocols. I also know there are vast differences between nursing theory and models versus the medical model.
So, from a professional and technical perspective, when a NP prescribes, is it a function of advance practice nursing or is the APN considered to be practicing medicine?
Just curious on your thoughts.
-T

One question, which I think relates directly to this topic, is what journals do NPs/DNPs read to stay up on the latest diagnostic/therapeutic advances? The Journal of Advanced Nursing (I flipped through a few month's worth) did not seem, at least to me, to have much practical stuff that would help the busy NP/DNP. Are there others out there that I don't know about? I would love to hear about some.

Trauma Columnist · Jun 18, 2008

To answer the OP's question, I too think that I practice medicine far more than nursing...that said, I utilize my nursing experience daily in order to make decisions that then lead me down the road to practicing medicine.

forpath - I'm in nephrology so I read specialty journals. I did once subscribe to an APN journal but since it wasn't specialized, I didn't get the info that I needed.

Advanced Practice Columnist / Guide · Jun 19, 2008

One question, which I think relates directly to this topic, is what journals do NPs/DNPs read to stay up on the latest diagnostic/therapeutic advances? The Journal of Advanced Nursing (I flipped through a few month's worth) did not seem, at least to me, to have much practical stuff that would help the busy NP/DNP. Are there others out there that I don't know about? I would love to hear about some.

The best way to go about finding the most authoritative and up-to-date information on patient management is to look through the pages of Tier 1 Medical Journals such as The New England Journal of Medicine and The Journal of the American Medical Association. Like traumaRUS also pointed out, some peer reviewed specialty journals are also excellent resources as far as medical management in specialty fields. I would also like to point out that just because these are journals that represent the medical profession doesn't mean that only physician-generated articles and research are published. Many of the articles approved for publication in these highly respected journals actually involve the work of a multidisciplinary team of health care professionals including non-physician providers such as nurse practitioners.

It may also come as a surprise to some that many of the well-respected nursing journals are also referenced and read by medical professionals because they actually appear when an Ovid/Medline search for an article is performed. For instance, not too long ago, one of the intensivists at work distributed copies of an article on Airway Pressure Release Ventilation published in a critical care nursing journal so that resident physicians during their ICU rotation can familiarize themselves on this emerging mode of mechanical ventilation.

jjjoy, LPN · Jun 20, 2008

In my opinion, most NPs practice medicine. I'd consider nursing practice to be those things that assist the patient in dealing with their disease - eg determining the most appropriate treatments for symptom management - as opposed to prescribing meds to cure the ailment - eg antibiotics. Yes, there's overlap there... as in dentists prescribing meds practicing dentistry or medicine? Presumably the dentist will keep their practice only on dental-related issues and refer other issues to an MD as opposed to treating it themselves - even if they know exactly what it is and what should be done. The more widely accepted definitions of nursing tend to *exclude* diagnosing and treating disease directly while describing activities to assist the patient in maintaining a quality of life and avoiding preventable deterioration.

If nursing truly wants to have its own domain (eg assisting patients in getting through and/or living with disease processes) then it can't try to claim all roles someone with a background in nursing might take. Thus, a nurse might do well functioning as a 'physician extender' diagnosing and treating disease processes, but they are not practicing nursing. If they then go on to develop a plan of care to cope with the disease process (eg antiemetics and pain control in a cancer pt), then they would be practicing nursing. Perhaps, then, an MD who takes up such care could be said to be crossing over into the realm of 'nursing care'?

My thoughts aren't well developed here, but just some thoughts on defining the differences between 'practicing nursing' and 'practicing medicine.'

Joan Z · Jun 21, 2008

I think of medicine as dealing with disease; nursing is dealing with response to disease. I like to think that as an NP I will be practicing health management. The domains are pretty blurred. I am concerned legally and usually say what I do is described by my license and by the state BON.

christvs, DNP, RN, NP · Jun 21, 2008

I will be soon practicing as a Hospitalist NP and when I shadowed 2 of the current Hospitalist NPs I could see quite clearly that they were practicing medicine, in my opinion. I think this because they spent their time examining patients, ordering diagnostic testing and labs, prescribing meds, and admitting patients in the ER and writing their admission orders. However, that being said, I do agree with others who have responded to this post: I think that I will be mostly practicing medicine as a Hospitalist NP, but also I will be using my nursing background to help me consider all the needs of my patients (emotional, psychosocial, spiritual) and not just focus on trying to "cure" them all as fast as possible. I am the kind of nurse who loves taking the time to answer patients' questions, address their concerns, give support, and I like to think of this as my nursing side. So this is how I believe I will be practicing as an NP-both medicine and nursing.

JDCitizen · Jun 29, 2008

I will be soon practicing as a Hospitalist NP and when I shadowed 2 of the current Hospitalist NPs I could see quite clearly that they were practicing medicine, in my opinion. I think this because they spent their time examining patients, ordering diagnostic testing and labs, prescribing meds, and admitting patients in the ER and writing their admission orders. However, that being said, I do agree with others who have responded to this post: I think that I will be mostly practicing medicine as a Hospitalist NP, but also I will be using my nursing background to help me consider all the needs of my patients (emotional, psychosocial, spiritual) and not just focus on trying to "cure" them all as fast as possible. I am the kind of nurse who loves taking the time to answer patients' questions, address their concerns, give support, and I like to think of this as my nursing side. So this is how I believe I will be practicing as an NP-both medicine and nursing.

Practice medicine? Its all in the eyes of the beholder. As a NP I am allowed to diagnose, order test, interpret test, order medications, etc...

Am I practicing medicine or advanced nursing???

The way one gets to practice is directly controlled by the one writing the paycheck. Ones ideals of of exactly how it should be/could be will be warped by necessity.

I practice advanced nursing in a world governed by medicine.

Vague explanation I know; sorry....

hypocaffeinemia, BSN, RN · Jun 29, 2008

This totally depends on how you define practicing medicine. The party line is that NPs practice advanced nursing, but common sense indicates there is a substantial overlap in scopes of practice between practicing medicine and practicing advanced nursing.

Of course, there's substantial overlaps in areas such as optometry and ophthalmology, dental surgery and ENT surgery, and podiatry and foot and ankle orthopedic surgery as well. I guess if we say such specialists practice optometry, podiatry, and dentistry, respectively, instead of practicing medicine the same should be said for NPs. The confusion comes from the fact NPs often share the exact same job roles as PAs who do practice (supervised) medicine, so it all comes down to how you define medicine.

If you go with a specific definition of medicine, you can argue against it, but if you go for a less anal and more generalized definition, then you can argue for it.

KatieRN04 · Jun 30, 2008

How I see it is, yes, nurse practitioners follow a nursing model by practicing as RN's first and governed by the board of nursing, however, that being said, the board of medicine does put up fights to the board of nursing on NP's, hence one of the reasons for the DNP being brought about. At least according to the instructors at the NP school I attend. NP's in some states can practice on their own without being associated with an MD, once again though, there is usually an indirect relationship with an MD for advice and networking. PA's follow a medical model since they are governed by the board of medicine.

As far as practicing medicine, from a nursing POV in an NP program, NP's kind of practice medicine to an extent, I would say. For example, if a pt comes to your office and appears to have an infection, the nursing diagnoses would be "Risk for infection", "Alteration in fluid and electrolytes", "Alteration in comfort". This would be unacceptable to bill insurance with these nursing diagnoses, so hence, a medical diagnoses is given, "sepsis", and IVF, Abx, electrolyte replacement, pressors, etc....depending on the severity of the infection.

Or for constipation or a small bowel obstruction, the nursing diagnoses would be "alteration in elimination". The medical diagnoses is constipation, small bowel obstruction and treated accordingly.

So depends on who you ask basically on practicing medicine. A PA would say an NP cannot, a NP can say yes since they understand what nurses do and this is a step up from nursing. If you step back though, both are midlevel positions, and neither are ever going to be doctors or medical specialists, and should refer pt's to MD's that are not within thier scope of practice.

jjjoy, LPN · Jul 1, 2008

My understanding is that as one looks back in history, "nursing" has generally been tending to the ill and infirm - the type of work often undertaken by family members, traditionally, female family members. Families of means might hire people into their home to help care for their infirm, and community institutions for the infirm would need workers. That has all been considered nursing traditionally. Those caring for infants and small children have also traditionally received the title of nurse. The role itself was one that theoretically anyone could minimally provide to their loved ones. Religious calling or financial desperation were what generally led people into working as a nurse; generally they were women with few alternatives for providing for themselves. After all, women weren't supposed to have to support themselves. Men were supposed to do that while the women took care of domestic issues.

On the other hand, doctoring developed more as trade - specific skills to be honed and practiced for a price. Doctors were men, the same men who were expected to provide for their wives and families. There was much more incentive and resources for them to build it up as a reputable profession. In the 1800's it seems, both nursing and doctoring solidified into more distinctive professional roles, with nursing generally being low-paid, low-skilled care for the infirm and doctoring generally being well-paid services to those who could afford it and requiring much more education and training than nursing. Though there were some women of means who chose to work as nurses for charitable reasons. Some of these nurses took their goodwill directly to the heart of poor communities, encouraging hygiene and child health and starting the tradition of public health nursing. There were also the nurses who worked directly as doctor's assistants, with the doctor training them up as much or as little as suited their own needs. These nurses migh be trained to administer anesthesia agents, for example.

In the 1900's there was the medical technology explosion. This is when hospitals as we know them today developed, with doctors admitting and directing medical care and nurses providing the day-to-day care. Physicians were predominantly well-educated men with financial resources. They were able to effectively band together to carve out their profession. Nurses were mostly women who either quit once they married or were of limited educational and financial background who had to work full-time AND take care of their families. No wonder they didn't have the same kind of influence as physicians.

So there continued to be quite a gap between nursing and doctoring even as functionally, they became more interdependent on each other and as both became dependent upon the quickly advancing medical technology.

Nursing also professionally separated itself from medicine. I realize the pressures to do so since medicine didn't want anyone encroaching on their domain anyway. But I'm not convinced that nursing as a whole was best served by the direction nursing as a profession took in attempting to define itself as an independent practice when the majority of those practicing nursing (eg, in hospitals) DO depend upon a doctors' practice for their livelihood. I can see, though, that nursing as a profession had incentive to specifically excuse itself from diagnosing and treating in order to be free from the direct oversight of the powerful medical lobby. Unfortunately, that leaves the role of the NP and some other advanced practice nurses difficult to define as "nursing" and to defend as not requiring the oversight of the medical community.

Financial pressures, though, are powerful and I think that's how NPs got a foothold and kept that foothold in the protected realm of medicine. However, with the expansion of PA programs and overall ramp up for more mid-level providers, it will be interesting to see how this continues to play out in the future.