I have been following your discussions here on the recent media coverage of the primary gap, and NPs place in it. I posted this on another forum that I moderate, and felt it was only fair to give you all a chance to chime in. I hope it doesn't come across as an attack, but rather a clinician of a different stripe with some real questions about how we market ourselves. The text below is addressed to PAs, so read in that context:
I have been reading the coverage of the recent articles from CNN and Time that we discuss here, in particular the responses on allnurses.
Of course I have to provide my PA disclaimer.....I work with NPs.....about a dozen of them at my institution. I have never had a negative experience with any of them, and have no need to write a "hit piece". We confer, they give medical feedback, I give surgical, etc....collegial and pleasant.
That being said, I have read over and over again about the presumed advantage NPs provide over docs (this is in their words) becuase they offer a "nursing perspective", "treat the patient, not the disease", "look at the patient as a whole", "offer prevention as well as treatment", etc.....
I really don't see this as NP bashing, but I see these comments as somewhat elitist....or at least "leading the argument". The NPs I work with practice the same medicine (!) as the rest of us, PAs, MDs, etc. Their preop cardiac workups look just like any other. And they're good. A clinic NP treating OM...are they really offering that much of an edge over a non-NP due to their nursing background? What does the nursing backgroud teach about listening, empathy, and thinking about interdependent body systems that our medical model education does not?
This all seems like a phoney selling point that is SO subjective that there is no way to argue it, putting NPs in a position which is easy to defend and impossible to refute.
Thoughts?
Do you feel like you treat your patients any less holistically b/c you were trained in the medical model?
I'm not so sure. If PAs can provide equivalent care to MDs/DOs- which there is evidence to support that I've seen for diabetic populations- then how do we prove that their efficacy (how "far" they get) is due to simply matching docs in the practice of standard western medicine vs this nebulous character of treating patients holistically?
This discussion seems to be going around in the usual pointless circles without actually going anywhere. My point was that, if NPs really do provide a different approach to treating and interacting with clients that clients find meaningful and worthwhile, NP practice will continue to flourish and expand (I mean in terms of their popularity and client populations, not scope of practice) -- the public will "vote with its feet." If not, and there's really no meaningful experiential difference between seeing NPs and seeing MDs and PAs, then that won't happen.
For what it's worth, my own experience over my entire adult life has been that MDs do hand you the scrip and show you the door, and NPs have been much more careful about gathering more detailed information about my sxs during the "exam" phase of the visit and about teaching/clarifying/discussing the ultimate dx and tx. I continue to see my long-time MD, who is v. good for an MD, because he has been my doc since long before NPs were available in my rural area and we've been through a lot together over the years, but I've always had good experiences when I've seen an NP in different situations over the years, and I certainly can't say that about MDs! (I can't speak to PAs because I've never seen one as a client and wouldn't do so if I had a choice in the matter.)
My dad is a MD. My brother is a PA, and I am an RN with aspirations for FNP. We have had many, many discussions/debates over topics very similiar to this one over the years.
I belive the "special" position often touted by NPs is multi-faceted. First, I believe it stems from a long standing tension between nurses and physcians. Right or wrong, it's there. I must say though that the team concept has definitely improved care and cooperation compared to the early years of my career. Nevertheless, nurses have worked hard to earn the respect we deserve and this carries over as NPs (we all started as staff RNs).
Second, as a staff floor nurse, I care for a patient and their families for 12-hour shifts. That amount of time gives me the opportunity to deal with questions/concerns, perform the care that's ordered, and witness the effect of illness and treatment. A MD most likely doesn't get that from a 5-10 minute visit with a pt during rounds. That experience is a common and unique background for most NPs. I believe over the years a nurse can gain valuable understanding and empathy for what a patient may need to recover from illness that may not be so obvious from a medical pespective.
Now don't get me wrong, nursing isn't "all that"! I am a vocal critic of many areas within nursing. It is not without its weaknesses and disappointments (the whole DNP thing for one)!
Quite frankly, I don't understand the tension between PAs and NPs. What two professions mirror each other in the practical application of their care? Seems to me, we stand to gain more by banding together in the fight for greater scope of practice, prescriptive rights, etc.
I don't question the unique role that nursing plays in patient care. As a PA who practices the majority of my time in critical care, nurses are my interface with patients on multiple issues, being first responders and assessors...with those assessments and interventions leading to saved lives, no doubt.....I wouldn't say that role is a point of debate.
The debatable point- that this clinical background as RNs (which more recently is less and less prevalent in new NPs)- confers a clinical advantage, has not been concretely resolved. Yes, there are NPs out there that address patient issues more throughly than a 5 min visit from another provider.
But I insist- I don't see it as 1) accurate or 2) fair to use this as a major point of distinction between NPs and non-NPs.
The points raised so far in this thread from individual posts:
NPs are more caring and compassionate than non NPs.
NPs have relatively less clinical training hrs but make up for it in bedside manner (and conversely, MDs/PAs have more clinical hrs but les bedside manner).
This argument is so subjective that there is no fair way to say with objectivity that NPs are better or worse at anything.
NPs treat "clients", not patients? :wink2:
I don't want to obfuscate the matters by arguing that one group (NP/PA/MD/DO) makes more or less clinical errors than the other, since I don't think that's the case. I certainly think that the interrelationship between PAs and their SPs (supervising physicians) play an important role in maintaining good care across the board, with that SP particiaption becoming less relevant as the PA gains more clinical experience. I wish NPs would maintain this opinion as well in their zeal for 50 state independence, but that's another thread!
The issue is not about errors or safetly, but about staking out advertising ploys in the public eye; about being disingenuous by claiming to have market share on caring, which by its nature creates a differentiation which can ONLY portray non NPs (PA MD DO) as less caring/uncaring. Is that the road you want to go down as professionals? Rather than stand by the merits of patient outcome?
I agree that more NPs are coming out of school with little to no "hands on" experience as an RN. I do feel this experience is valuable and critical. In the same way I feel a PA/MD is also missing something when their first meaningful patient contact is during their first year of school.
The "more clinical hours" argument that I get from PAs is also debateable. PAs receive an education involving all areas of medicine. Valuable? absolutely. The difference is that NPs pick their specialty and the program is focused only on that specialty. A Neonatal NP would gain little from the 6-week trauma rotation that a PA gets.
You describe a predjudice against Medical providers (MDs/PAs) as being uncaring and "script at the door" care givers. You objected to the notion that NPs claim market share on caring. You noted a couple of stereotypes that are equally frustrating. Stereotypes and predjudice by their nature are inaccurate and unfair at best.
For example, How many TV shows glorify the superhero qualities of the MD? Giving little to no recognition to the rest of the "team". You and I know differently, but the general public doesn't. Perhaps a weak example, but it illustrates the perpetuation of a certain stereotype and predjudice. Additionally, the positive public perception of the "caring nurse" is subjective, but also real and measurable relative to other professions. Why would that not carry over to a nurse practioner?
The 50 state independence crusade, isn't much more than a turf war! I'm sure the NPs you work with are very much interested in a collaborative practice environment within their communities. The road to get this far wasn't paved by the AMA, in fact, quite the opposite! If the outcomes are the same, what is the argument against independent practice? Its political and economic turf. Personally, I can't imagine practicing good patient care without a solid relationship with other providers in much the same manner that PAs do.
Maybe it boils down to this: Nursing's mantra has been "caring and compassionate care" since Florence Nightengale. Do we do it better than anyone else? No, not necessarily. To be in any healthcare field I believe you need that fulfillment that helping someone gives you.
I agree that more NPs are coming out of school with little to no "hands on" experience as an RN. I do feel this experience is valuable and critical. In the same way I feel a PA/MD is also missing something when their first meaningful patient contact is during their first year of school.
I don't follow....PAs spend their entire 2nd yr in clinical rotations, with introductory H&P skills during the first yr. MS's spend yrs 3/4 in clinicals...??
The "more clinical hours" argument that I get from PAs is also debateable. PAs receive an education involving all areas of medicine. Valuable? absolutely. The difference is that NPs pick their specialty and the program is focused only on that specialty. A Neonatal NP would gain little from the 6-week trauma rotation that a PA gets.
That's a philosohical difference; PAs/MDs have generalist education, NPs don't. I think there is value to an adult NP who has been exposed to all types of adult pts in training.
You describe a predjudice against Medical providers (MDs/PAs) as being uncaring and "script at the door" care givers. You objected to the notion that NPs claim market share on caring. You noted a couple of stereotypes that are equally frustrating. Stereotypes and predjudice by their nature are inaccurate and unfair at best.
For example, How many TV shows glorify the superhero qualities of the MD? Giving little to no recognition to the rest of the "team". You and I know differently, but the general public doesn't. Perhaps a weak example, but it illustrates the perpetuation of a certain stereotype and predjudice. Additionally, the positive public perception of the "caring nurse" is subjective, but also real and measurable relative to other professions. Why would that not carry over to a nurse practioner?
I think it's funny that recently there has been a shift in the TV shows, for whatever that's worth...shows like "Nurse Jackie" and "Hawthorne"....even "ER" did it yrs ago- portaying issues where the nurse is protecting the patients from doctors that are too young to know anything or too hurried to take the time.
I'm sure that the bedside manner necessary to be an RN carries over to an NP; I just don't think they have a monopoly on it, enough to be used as a distinction between NPs and docs, or to say that "if you want a caring provider, see an NP".
I was a home a HHA and CNA before PA school. I wiped plenty of butt. I drove out to the sticks in north Florida to take care of people with no electricity, no running water, etc....and there are plenty of other PAs with similar levels of dedication, with experience as EMT, RT, RRT, medic, RN (!), MA, etc.....in the health care environment we are in today, it seems like a good opportunity to band together and say that we ALL have providers who treat the whole patient, who are dedicated, who look at more than just the dx, etc. The reason I said the "whole pt" thing was a phony selling point.
The 50 state independence crusade, isn't much more than a turf war! I'm sure the NPs you work with are very much interested in a collaborative practice environment within their communities. The road to get this far wasn't paved by the AMA, in fact, quite the opposite! If the outcomes are the same, what is the argument against independent practice? Its political and economic turf. Personally, I can't imagine practicing good patient care without a solid relationship with other providers in much the same manner that PAs do.
I'm not so sure. Of course some here will take this badly, but the a new grad DNP, particularly one who has little to no RN experience, should not be practicing indpendently. That's not about turf, it's about the ability to provide the level of expertise the pt needs.
Maybe it boils down to this: Nursing's mantra has been "caring and compassionate care" since Florence Nightengale. Do we do it better than anyone else? No, not necessarily. To be in any healthcare field I believe you need that fulfillment that helping someone gives you.
"The issue is not about errors or safety, but about staking out advertising ploys in the public eye; about being disingenuous by claiming to have market share on caring, which by its nature creates a differentiation which can ONLY portray non NPs (PA MD DO) as less caring/uncaring. Is that the road you want to go down as professionals"? Hmmm market practice is market practice (Chevy does not like Ford's advertisements either). I dare say that the market practices of some other groups are far less as nice.... I am from Georgia and I will directly mention the Georgia Medical Association..
"Rather than stand by the merits of patient outcome"? I believe we are building a fairly strong record on patient outcomes.. I believe as long as one party or the other is doing the research there will be no happy answers here or at least not until and independent entity comes up with results.
The compassionate issue: We all have probably failed at this more times than we would like to mention no matter our background.
"In PA/MD training, the H&P is drilled in from day one" Might be drilled in but not always practiced in the real world. (Not attacking PAs here) but I have seen H&Ps copied from prior H&Ps and consulting H&Ps copied verbatim by consulting parties. Years of practice has seen this enough to be able to say its not that rare. I have called many a doctor to advise them that my H&P does not jive with their H&P. Did I catch flak oh yes I did but my patient was taken care of.
"PAs have 2000 - 10000+ hrs previous health care experience before PA school (although unfortunately more and more PA programs are accepting PA students with minimal previous HCE..a bad trend that many of us PAs disagree with".... Might be more than a bad trend most of the PAs I know had no experience prior to PA school and none of the ones with over 15 years of experience had any prior healtcare experience other than a family member... But this "trend" is hitting NPs also....
Thought: How does one get/learn the nursing perspective? If programs keep turning out advanced nurses who were not nurses to begin with one could argue that the nursing perspective must be something that is taught and not gained with experience...
I know my perspective was shaped over years of 8, 12, 16 hours shifts with patients and their families. Year after year I have seen firsthand over multiple hours and days the difficulties that illness and disability can bring down on the family as a whole.
After years of practice as a NP I know that I don't always get to really bring out the "nurse" in me. Its not necessarily because I don't want to but because the patient does not care: Sometimes its only about the patient seeking a diagnosis and an answer.
"I'm not so sure. Of course some here will take this badly, but the a new grad DNP, particularly one who has little to no RN experience, should not be practicing independently. That's not about turf, it's about the ability to provide the level of expertise the pt needs". Read my other postings and you will know my thoughts of the DNP program but I have been around long enough to say this applies to all parties..... Over the years I have been around many new nurses, NPs, PAs, MDs, etc... I have been that new nurse, that new NP.... I am 100% for collaboration.
Mentioning trends it seems we both might agree our groups are sometimes their own worst enemies...
The poster presents an interesting question. In my extensive experience as an FNP (serving the community since last Tuesday) I often wonder about this myself. I'm a full partner in the place where I did my internship--a 35K pt practice with three other NP's and two docs, and I've noticed that my bookings are three weeks in advance where if you want you can get an appointment with one of the MD's in 2-3 days. The other NP's are crazy swamped too. The senior NP is 6 weeks out unless its for follow up.
During my internship and presently, I always take a few minutes with my new patients and explain the differences between the nursing and medical modle. Not from a selling perspective, but to give them an idea of why I'm asking about their bowel patterns, last PAP, if they do SBE's and the other litany of questions when they are just there for upper respirtory infection type complaints. When I explain to patients that nursing involves itself with looking at the entire picture of an individual, in the context of family and community with nursing paradigms influencing one another, I kind of get the idea they have never had a health service similar in their physician relationships.
I'm not sure if this is a "phony sell" or not, but then again, if you want to make an appointment with one of our NP's, be prepared to wait several weeks--unless you are OK with an earlier appointment with one of our less phony MD's. They are good too.
On the topic of clinical hours, don't discount the hours of clinical training when in school to become an RN as well as the hours while in our NP programs.
One should work as an RN before going into an NP program. I gained valuable experience as an RN. I understand the importance of ordering an IM injection if possible over an IV injection when the nursing staff is strained.
I am not the same as a PA or MD. My training was different and I prefer the nursing model over the medical model. It works for me. If the medical model works well for others, that's okay too.
The important thing is to let patients have a choice. Some patients may prefer the nursing model over the modical model and vice versa.
On the topic of clinical hours, don't discount the hours of clinical training when in school to become an RN as well as the hours while in our NP programs.
One should work as an RN before going into an NP program. I gained valuable experience as an RN. I understand the importance of ordering an IM injection if possible over an IV injection when the nursing staff is strained.
I am not the same as a PA or MD. My training was different and I prefer the nursing model over the medical model. It works for me. If the medical model works well for others, that's okay too.
The important thing is to let patients have a choice. Some patients may prefer the nursing model over the modical model and vice versa.
T
I have to plead some ignorance here, but what is the nursing model? In relation to patient care (meaning not nurse education/leadership/etc)....NPs practice nursing, not medicine. You're outside the BOM.
I ask b/c plenty of NPs I have spoken to have said they feel the "nursing, not medicine" concept is bogus (their sentiment, not mine). So when a NP treats bronchitis, or does a preop cardiac eval, how are they not practicing medicine?
Is the paractice of Nursing "Medicine Plus Something"? An X factor that we can't describe? How (concretely) is the practice of nursing different than the practice of medicine?
The poster presents an interesting question. In my extensive experience as an FNP (serving the community since last Tuesday) I often wonder about this myself. I'm a full partner in the place where I did my internship--a 35K pt practice with three other NP's and two docs, and I've noticed that my bookings are three weeks in advance where if you want you can get an appointment with one of the MD's in 2-3 days. The other NP's are crazy swamped too. The senior NP is 6 weeks out unless its for follow up.
During my internship and presently, I always take a few minutes with my new patients and explain the differences between the nursing and medical modle. Not from a selling perspective, but to give them an idea of why I'm asking about their bowel patterns, last PAP, if they do SBE's and the other litany of questions when they are just there for upper respirtory infection type complaints. When I explain to patients that nursing involves itself with looking at the entire picture of an individual, in the context of family and community with nursing paradigms influencing one another, I kind of get the idea they have never had a health service similar in their physician relationships.
I'm not sure if this is a "phony sell" or not, but then again, if you want to make an appointment with one of our NP's, be prepared to wait several weeks--unless you are OK with an earlier appointment with one of our less phony MD's. They are good too.
Sarcasm not lost on me.
May I ask- when you "explain the differences between the nursing and medical modle (sp)", what do you say? What is the NP explanation of the difference?
Does a non NP in a FP setting such as yourself NOT ask about chronic health maintenance? Bowel patterns? Standard screening guidelines? These are routine matters for PC, no?
A nursing model it is a collection of theories and concepts which incorporate evidenced based research to form a framework within which to work. This framework helps assess the patient's needs, plan and provide the appropriate treatment/care.
There are several nursing theorists. I'm a fan of Neuman's model.
elkpark
14,633 Posts
This discussion seems to be going around in the usual pointless circles without actually going anywhere. My point was that, if NPs really do provide a different approach to treating and interacting with clients that clients find meaningful and worthwhile, NP practice will continue to flourish and expand (I mean in terms of their popularity and client populations, not scope of practice) -- the public will "vote with its feet." If not, and there's really no meaningful experiential difference between seeing NPs and seeing MDs and PAs, then that won't happen.
For what it's worth, my own experience over my entire adult life has been that MDs do hand you the scrip and show you the door, and NPs have been much more careful about gathering more detailed information about my sxs during the "exam" phase of the visit and about teaching/clarifying/discussing the ultimate dx and tx. I continue to see my long-time MD, who is v. good for an MD, because he has been my doc since long before NPs were available in my rural area and we've been through a lot together over the years, but I've always had good experiences when I've seen an NP in different situations over the years, and I certainly can't say that about MDs! (I can't speak to PAs because I've never seen one as a client and wouldn't do so if I had a choice in the matter.)