Do NP's Practice Medicine?

[Dr. Tammy, FNP/GNP-C]

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

[JDCitizen]

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.

Hmmm good discussion I love veiw points of others.. Oh my goodness that must mean I am not a doctor :chuckle

How many doctors could survive in the practice they know now w/o nurses and vice versa? Maybe it can be said that nursing had to evolve so we could better advocate for the patients we serve?

There is a lot that the medical community whines about in public when in fact a large part of that medical community has been doing just the opposite. I have see doctors delegate /relegate there duties to RNs and at times LPNs. Just to list a few: standing orders, signed prescription pads, tests/procedures ordered, H&Ps and D/C summaries, permits.

The overall outcome may not be what any of us want. It's really going to boil down to "financial pressures" which means what the patient wants. But I doubt the feature of health care will be delivered as a monopoly.

Probable Future:

1) Technology is going to keep advancing enabling the sicker and sicker to live longer. We see this now.

2) The hospital population and general population are going to be sicker than we can even imagine especially with the baby boomers peaking. We can't meet the demand we have now.

3) Health care as we know it know is going to crash. There is no way the general population can support itself with all these financial pressures (Gas, food or medicine, etc).

Look at hosptials now ventilators on floor patients, cardiac monitoring and drips on floor patients, etc.. etc,,, All these used to be ICU type things

We have a whole group of doctors that are called hospitalist but they have evolved to not staying in the hospital.

The hospitals that doctors and nurses have come to depend on to survive are struggling to survive and so far for the most part the medical community has not come to there rescue. So the nature of the beast needs a solution and why not nurses..

The days of the caveman came to an end and the horse was replaced by the car...

Maybe no replacement but team work will keep us all employed???

[straba]

Most NP's, particularly in inpatient settings, practice medicine (under the guise of "advanced practice nursing). I'm sorry , but simply calling the sun the moon, does not make it so. Just my .02

[prairienp]

Most NP's, particularly in inpatient settings, practice medicine (under the guise of "advanced practice nursing). I'm sorry , but simply calling the sun the moon, does not make it so. Just my .02

Here I thought I had been practicing health care for the past 30 years

[JDCitizen]

Here I thought I had been practicing health care for the past 30 years

[Dr. Tammy, FNP/GNP-C]

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.

Again, another example of how medicine and advance practice nursing function overlap, yet the function cannot be owned by any particular discipline by suggesting the utility of ICD diagnostic categories belong to medicine and applying such codes for clients are the practice of medicine. To the regret of the medical establishment, the term "medical" is conspicuously absent from the the ICD nomenclature "International Statistical Classification of Diseases and Related Health Problems"

[JDCitizen]

Little more to add to the pile here...

Medicine: complimentary medicine, herbal medicine, alternative medicine, folk medicine, traditional, non-traditional....

Nursing(according to who): King; Abdellah; Erickson, Tomlin & Swain; Henderson; Leininger; Levine; Newman; Nightingale; Orem; Orlando; Porifice; Josephine Paterson & Loretta Zderad; Peplau; Rogers; Nancy Roper, Winifred W. Logan and Alison J. Tierney; Roy; Watson; Wiedenbach; Orem; Sieloff; Kolcaba; Mercer.........

Of course when we nurses worry about what type of health care we deliver and other semantics the "doctors" are laughing all the way to the bank...

I have forgotten to mention that there are plenty of nurses that dislike APRNs out there also......

[jjjoy, LPN]

Here's my take on it...

Think of an elementary school teacher. In the course of teaching she (gotta choose one pronoun or the other) learns to recognize dyslexia, ADHD, and other disabilities that can impede learning. She becomes very interested in these problems decides to become a learning consultant, hired by concerned parents to help with learning challenged kids. Strictly speaking, is she still "teaching" professionally? I'd say no. I'd say she's a learning specialist with a teaching background. Having a teaching background can be one way to become a learning specialist and can be a great asset, but someone else might come to it from a different direction - such as from a childhood development angle - and never have taught a classroom full of kids.

So using that kind of narrow definition, I'd say most NPs are not practicing "professional nursing" (which I'll define narrowly here as helping patients deal with disease states/chronic disease) much of the time - they are practicing medicine (here using the broad sense of the term in regard to diagnosing and treating medical conditions). Their background in nursing is an asset, helped them get where they are, and is drawn upon in their work, but others can get to the same place from a different direction, such as PA training.

I realize that definition of nursing cuts out things like preventative care, but I see preventative care as something that ALL health professionals engage in, and not uniquely "nursing". Nurses are good at it, but other professionals could be trained to do that well, focusing specifically on preventative care, without needing to cover the full spectrum that a nursing education covers.

Just thoughts! My perspective keeps changing!

[dhigbee]

I've decided that I no longer care what you call it. I just want to take care of my patients' healthcare needs to the best of my ability. To do that I pull from many disciplines (nursing, medicine, psychology, teaching, counseling, PT, and so forth).

Dana