Hate "Midlevel"

Pilot2FNP · Sep 13, 2014

I never really gave it much thought, but after reading this article, I have to agree. It really opened my eyes. Kudos to Dr. Michael Pappas!

Thorn.ACNP.RNFA · Sep 13, 2014

I've never taken offense to the term and don't see it like the article you posted. He made one excellent point though. Once you starting providing healthcare at any level, you decide what type of care you provide. You may decide how efficient you are at your role and how competent your patient care is, but that does not change what level of autonomy, decision making, and responsibility comes with your credentials.

Bedside nurses are the most vital part of the team. They monitor the patients status and are the direct informer and advocate to the doctor. On the hierarchy of decision making though, they are on the lower level. Although their input greatly effects POC, they do not have it in their scope to write medical orders and make these decisions.

"Mid-levels" or NP's and PA's have had specific training and certifications to enable them some autonomy. This greatly varies from state to state and even hospital to hospital. You see this even more in the hospital setting than the clinic. They can assess, make diagnostic decisions, and then write medical orders. This is because of their higher scope of practice. While they can make these decisions somewhat "autonomously", it must fall under the cloud of a collaborative physician. In the hospital setting major medical decisions and surgical decisions must still be made either with collaboration of a physician or by the attending physician. Therefore midlevel makes perfect sense to me, as it is not saying my care is middle of the road but is "middle" of the ladder of legal hierarchy.

MD's do not always provide a "higher" or better level of competent care. But none the less, they are the top of the medical totem poll. It really has nothing to do with the fact they some of the ones in specialty practice had educational careers toping 15-20 years, it is simply a legal matter that they are licensed to provide medicine.

I see your point, but just look at it from a different angle.

-Chris

allnurses Guide · Sep 13, 2014

While they can make these decisions somewhat "autonomously", it must fall under the cloud of a collaborative physician. In the hospital setting major medical decisions and surgical decisions must still be made either with collaboration of a physician or by the attending physician.
Therefore midlevel makes perfect sense to me, as it is not saying my care is middle of the road but is "middle" of the ladder of legal hierarchy.
MD's do not always provide a "higher" or better level of competent care.
But none the less, they are the top of the medical totem poll.

I feel compelled to make a few comments, they aren't directed at the poster, just good for thought.

Now in 19 states NPs CAN practice autonomously without a collaborating physician. The question to be asked is why can't NPs practice autonomously? The outcomes for NPs have consistently been demonstrated to be equal or superior to that of our physician colleagues. If outcomes are the same, what is the true motivation for requiring NPs to have collaborative agreements with physicians in over half the country. Follow the money....

I am not the middle of any hierarchical ladder. I am held to the same responsibility, make the same decisions as, and have the same scope at my medical physician colleagues. I sign the orders and take the responsibility. There is no middle ground. I suspect other APNs feel the same.

Exactly right, they don't provide higher or better care! So why should they be required to supervise?

Why again are they on the top of the totem pole? Because historical they have been?

Sent from my iPhone.

Thorn.ACNP.RNFA · Sep 13, 2014

Seriously.... I just typed a book and it didn't post :banghead:

Thorn.ACNP.RNFA · Sep 13, 2014

@bostonFNP

I would agree with the majority of what you said. I have been well respected throughout my nursing career. I as bedside RN, I had plenty of MD's view me as their colleague. I'm currently completing a specialty in CV and the senior surgeon has extended a job to me as a "partner" not a mindless extension. Those are his words.

You've brought up some good points and my earlier post is more of the current situation in MS and after thinking about your post it isn't exactly how I believe it should be.

I'm currently fighting a something very similar to this at the hospital I work at. I have been thoroughly trained in special procedures during my education. I have placed 3 central lines this last week. But the hospital medical credentialing board has never credentialed a "mid-level" to do procedures. I think that is absurd. The doctors on this board have not done 3 central lines in the last 5 years combined. I would bet anything that my competence far outweighs theirs on special procedures and even handling issues that may arise. Just because they have MD behind their name does not make them superior.

I've seen some of my school mates though that could be scary without supervision, :roflmao: but I bet the same is said for medical school classes too.

I appreciate your comment. It's made me think of somethings a little differently.

LadyFree28, BSN, LPN, RN · Sep 13, 2014

I have never called a PA or NP "midlevels"; they are clinicians, and I will call them as such. :yes:

allnurses Guide · Sep 14, 2014

@bostonFNP
I've seen some of my school mates though that could be scary without supervision, but I bet the same is said for medical school classes too.
I appreciate your comment. It's made me think of somethings a little differently.

That why everyone should precept students. I am tough in my students and other NPs should be too. I worry sometimes that people slide by....but have you ever worked with a new bunch of interns, might be scarier.

Again, I wasn't trying to speak directly to you, just in general. But I am very glad you have at least glanced on it from another perspective after my post.

Sent from my iPhone.

TX911 · Sep 14, 2014

Nurses are so funny. They just concentrate on the minutiae of absolutely everything. Saved your patient's life through 12 hours of hard work? Don't care, you forgot to relabel the IV lines. Doctor of Nursing PRACTICE curriculum? I know, let's add about a billion utterly useless "theory" courses. Don't have an M.D., D.O., or PhD? Don't care, don't call me mid-level!

/mini-rant

I'm currently in a "DNP" CRNA program which thus far has been underwhelming to say the least. Out of 2 semesters we've taken one useful course- Advanced pharm. The rest of this stuff is more of the same ol' nursing fluff that every other profession laughs at. That's why we are considered mid-level; because we are.

allnurses Guide · Sep 14, 2014

That's why we are considered mid-level; because we are.

"We" aren't anything. You are a student early in your education, not an APN, so hold off on considering yourself one until done with your education and certified/licensed.

Sent from my iPhone.

seanynjboy, BSN · Sep 15, 2014

Now in 19 states NPs CAN practice autonomously without a collaborating physician. The question to be asked is why can't NPs practice autonomously? The outcomes for NPs have consistently been demonstrated to be equal or superior to that of our physician colleagues. If outcomes are the same, what is the true motivation for requiring NPs to have collaborative agreements with physicians in over half the country. Follow the money....

Just curious, has it changed to where an NP can write Home Health orders or sign a patient onto hospice yet? I used to work for an NP in Arizona in 2013 and at the time she still needed the collaborating physician for his signature for ONLY those two things. She said that there was some legislation in the works to get rid of that. I just didn't know if it got voted on or went into effect yet. The NP I worked for has her own practice and only sees patients via house-calls. With AZ being a very large retirement state, she is doing very well. :)

I personally hate the term mid-level as well. Unfortunately, in the state that I now live in (NJ). NPs cannot practice on their own. Apparently, it may change soon in NJ I just read.

Susie2310 · Sep 15, 2014

[quote=BostonFNP;8120873

Now in 19 states NPs CAN practice autonomously without a collaborating physician. The question to be asked is why can't NPs practice autonomously? The outcomes for NPs have consistently been demonstrated to be equal or superior to that of our physician colleagues. If outcomes are the same, what is the true motivation for requiring NPs to have collaborative agreements with physicians in over half the country. Follow the money....

I am not the middle of any hierarchical ladder. I am held to the same responsibility, make the same decisions as, and have the same scope at my medical physician colleagues. I sign the orders and take the responsibility. There is no middle ground. I suspect other APNs feel the same.

Exactly right, they don't provide higher or better care! So why should they be required to supervise?

Why again are they on the top of the totem pole? Because historical they have been?

Sent from my iPhone.

Master's level NP training clinical hours at the prominent university NP programs I checked was from the mid four hundred hours to 600 clinical hours. Contrast that number to the number of hours US trained physicians spend in medical school, internships, residencies and specialty training. I would suggest that the enormous difference between NP education and training and physician education and training has something to do with the situation you are referring to.