In Support of Independent NP Practice

Specialties NP

Published

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Personally, I think the direct-entry programs will transition from MSN programs to DNP programs[/quote

*** The DE programs I was refering to are the DE basic RN programs, not APRN DE programs. A person with a undergrad degree in another field enters a MSN program and comes out a new grad RN, not a APRN. They seem quite popular in this area (the upper midwest), despite the fact that many grads have great difficulty finding jobs as the programs are often not well regarded by employers. They suffer from a confusion between the DE APRN programs and the DE basic RN programs at the MSN level. Part of the DE APRN program involved spending a year or so learning to be an RN, then working as an RN for a year or so, then returing for the NP portion of the program. Many nurse managers hired these people and were dispayed to find that they were leaving just when they were becomeing useful to the unit (at one year) to finish the NP portion of the program. This created a lot of hard feelings as the RN knew ahead of time they would only stay 12 months and yet accepted a lot of training like critical care nurse residency programs, without any intention of staying to complete their contracts.

As a concequence the MSN DE basic RN grads have faced difficulty getting hired by nurse managers who don't understand the difference between MSN DE APRN pprograms and MSN DE basic RN programs.

I was asking what your opinion of the entry level MSN programs for RNs (not APRNs) was. Where would they fit in your ADN-LPN, BSN-RN, DNP-NP track.

Not to veer too much off topic here, but it's amazing how confusing and labyrinthine Nursing education is. It boggles the mind that so many different educational pathways lead to the exact same RN licensure with the exact same scope of practice. And, worst of all, it's usually for the exact same pay grade, too.

Why on earth would someone peruse a direct entry MSN program that only results in being able to sit for the same RN-NCLEX that a ADN grad sits for?

Different educations and scopes for LPN, RN, NP I get. That makes makes perfect sense. Completely different educational paths for the exact same RN license I don't get so much. Am I missing something? Is there a reason?

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
And, worst of all, it's usually for the exact same pay grade, too.

*** I would say "Best of all it's for the same pay".

Why on earth would someone peruse a direct entry MSN program that only results in being able to sit for the same RN-NCLEX that a ADN grad sits for?

*** It's a win-win for the student and the university. The student, who already has an undergrad degree and can no longer recieve student aid for a second bachelors degree, can go the graduate school and be elligable for financial aid. The university wins by selling a community college education at graduate school prices.

?

Trivial. Elementary. Overly simplistic. Obvious. Unimportant to the matter at hand.

Completely relevant to the matter at hand.

OP here.

Not surprisingly, this thread has taken many twists and turns that have taken away from the original intent in starting the discussion in the first place. I'm partly to blame by posting links without clarifying why I did so. I live in California, a restrictive state in terms of NP regulation, but nevertheless one among many that are in the face of an impending primary care provider shortage as the full implementation of the Affordable Care Act nears. As such I was hoping to get the discussion focused on primary care. After reading the succession of posts, many points have been brought up along the way and I would like to clarify some of the arguments made.

1. This thread is not about physicians and nurse practitioners being equal. Hardcore proponents of nurse practitioners are the first to argue that NP's belong to nursing's family of healthcare professionals and do not have the same amount of training as physicians who went to medical school. This is precisely the reason why NP's should never be regulated by a profession (Medicine) that it does not belong to nor "supervised" by an entity other than it's own.

2. Nurse practitioners ARE providing primary care in all the 50 states. Because scope of practice regulations are not uniform across the board, autonomy manifests itself in various forms depending on which state one practices and how institutional policies shape roles. Roughly thirty percent of states allow NP's to practice without a requirement in writing for a physician to supervise, collaborate, or "work under". The federal government through CMS which insures individuals under Medicare and Medicaid already calls for direct reimbursement of NP's for the services they provide. Physician presence is not a requirement per CMS regulation but ultimately, NP's are bound by their state's requirements for physician involvement if at all required.

3. NP's who own their practice (also referred to as NP business owners) are a minority. Not surprisingly, their presence can be seen even in states where independent practice is not the law. Because not all state regulations call for physician presence, these individuals are able to practice with a piece of documentation formalizing the required collaboration and periodic chart reviews.

4. NP's, by virtue of being nurses, fall under the "Most Trusted Professionals" for 11 consecutive years as of 2012. Nurses have an innate tendency to self-regulate their practice, seek to collaborate with experts, or consult other professionals. Nurses are aware of their limitations and new graduates of nurse practitioner programs are not going come in droves hanging up a sign offering independent healthcare services. We do not see that happening in states where independent practice is the law. As was already mentioned, no NP practices in isolation as every NP collaborates, consults, and seeks assistance from experts regardless of legislation.

5. Primary care is broken and fragmented in this country. Politically-driven or not, ACA is now law which raises the question of how our entire population will gain access to primary care.

6. I have never met an NP who does not advocate for leaving the choice of provider to the patient. Posters who state that they they prefer to see physicians for themselves and their families are free to continue to do so. Feelings won't get hurt and life will move on. On the flip side of that, there are individuals who prefer to see a nurse practitioner for primary care.

7. Though strong statistical data on NP demographics are lacking, the poster that says majority of NP's do not go into primary care have no basis for that statement. Surveys from Advance and AANP show that the biggest number of NP's work in clinics and hospital-based NP's are a minority. That is remarkable given the barriers that exist in practice.

8. I will not argue the studies that support the quality of care NP's provide. Posters who continue to oppose the validity of these studies have a pre-existing bias to begin with coupled with the fact that no one will be able to produce a perfect study. However, nobody has come up with the challenge of proving that independent NP practice has harmed patients. And no, that poster that mentioned the "missed sepsis" diagnosis does not count. I am a nurse practitioner working in critical care and I can tell you that we've admitted patients in multi-organ failure due to sepsis who were previously seen in the out-patient setting by a primary care physician who did not feel that hospitalization was necessary when they initially presented. Has that tarnished my opinion of the entire medical profession? of course not.

9. This is not a discussion arguing the need for attaining the highest level of nursing education. I am not advocating for the DNP nor the right to be called "doctor" based on one's academic degree. There is no point in suggesting that NP's feel superior to others in the nursing field. The NP role is a distinct role.

10. Finally, I have no vested interest as a nurse practitioner in becoming an independent provider. I am an Acute Care Nurse Practitioner in Critical Care at a medical center operating under one of the top nursing, pharmacy, dental, and medical schools in the US. We have primary care NP's seeing patients in our many clinics as well.

I will never be "independent" in this setting. I am in awe of the expertise of the double and triple boarded physician specialists I collaborate with everyday. But our patients accept for example that a nurse practitioner will be placing their loved one's triple lumen central venous catheter so that we can provide IV vasopressors and monitor hemodynamic parameters.

The medical center have always fostered this spirit of collaboration between nurses and physicians. As one of our chiefs once remarked, "medical students and house officers need to learn to work collaboratively with nurse practitioners because this is the trend in healthcare now". It's time for everyone to play nice in this sandbox.

Juan, in regard to the missed sepsis diagnosis, when it is your family member it counts.

Juan, in regard to the missed sepsis diagnosis, when it is your family member it counts.

That's not the point! The point is that it could have just as easily been an MD that missed the Dx as the NP in your case. Empirically it was just as likely to have been MD. Physicians are not gods,as much as they like to think they are, and NPs are more than capable of providing care within their training. They might not have done a residency or gone to medical school but they are trained to do what they do. So go ahead, no one is stoping you from insisting on having an MD for your primary care. While your at it make sure you only go to an opthamaligist when you need glasses, insist that only an anesthesiologist put you under if you ever need surgery, only go to a psychiatrist if you need therapy, or whatever other specialist you need. Good luck getting care.

I don't understand how or why someone would go into a arnp position or school without any nursing experience. I considered it at least after 5 years of practicing as an RN and I wouldn't say that I'm an expert but safe and quick on my feet when a patient starts to crash. I think it's called advanced practice nursing for a reason not advanced placement and yes I do agree that our programs should prepare us better for the medical aspect of managing clients. It's bad enough already that most of us have to earn our respect. I am all for independent practice but the programs needs to be overhauled a bit with residencies perhaps.

Specializes in Adult Internal Medicine.
I don't understand how or why someone would go into a arnp position or school without any nursing experience. I considered it at least after 5 years of practicing as an RN and I wouldn't say that I'm an expert but safe and quick on my feet when a patient starts to crash. I think it's called advanced practice nursing for a reason not advanced placement and yes I do agree that our programs should prepare us better for the medical aspect of managing clients. It's bad enough already that most of us have to earn our respect. I am all for independent practice but the programs needs to be overhauled a bit with residencies perhaps.

You aren't the only one that ponders this!

The data tells a simple story: those that have prior nursing experience truly value it in there practice, but there is little evidence to support that it betters outcomes or competency. There is obvious there is something valuable to it though.

More to the point, no novice NPs should be looking to start their own independent practice without a considerable safety net. Novice NPs may benefit from indecent practice though, in regards to practicing in NP run clinics and to the full extent of their education and practice.

FYI my "collaboration agreement" is four of five sentences long and simply states that I will practice within my scope guided by evidence and outcome based recommendations as possible.

I agree that no novice NPs should open up an independent practice, that's just a recipe for disaster. If we want to improve NP practice then I think we should require more hours of NP training and encourage more residencies (although this appears to be expanding).

More training hours, advanced anatomy & physiology, lab pathology, introduction to radiology would be a nice replacement to current courses like introduction to adv. nursing practice, adv role and policy, community health, nursing theory/ethics etc.

That's not the point! The point is that it could have just as easily been an MD that missed the Dx as the NP in your case. Empirically it was just as likely to have been MD. Physicians are not gods,as much as they like to think they are, and NPs are more than capable of providing care within their training. They might not have done a residency or gone to medical school but they are trained to do what they do. So go ahead, no one is stoping you from insisting on having an MD for your primary care. While your at it make sure you only go to an opthamaligist when you need glasses, insist that only an anesthesiologist put you under if you ever need surgery, only go to a psychiatrist if you need therapy, or whatever other specialist you need. Good luck getting care.

Not as probable. Seriously....but that's the difference in education, training, mentoring...even selection in the first place in many cases.

Whatever with the teen % for Nps in the hospital. In my region, hospital nps make up a heavy percentage. It doesn't matter, however, b/c, most nps are not working in remote areas of desperate need. They are no different from most doc in this regard. That's truly what I meant. So it's about making laws by exception.

Whatever, I seriously doubt if anyone will change or even dare to change their view...

It is about moving into medicine, bc that's what is being done.. Writing scripts for drugs is medicine. Ordering dx tests is medicine. I could go on, but really what is the point?

I question really what's going on whereby nurses (and often rns that are barely experienced nurses) go to graduate nursing school to practice medicine, unless a nurse is going to an area of true, serious need...very rural areas for example. But this is NOT generally the case.

I'm not telling anyone what to do or not do; but I do believe, for the most part, the practice of medicine professionally should mean medical school--and all that goes along with it.

I am sorry if that perspective bothers some folks.

Again, talk to nps that went on to med school and residencies and fellowships. You will get honest insight.

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Juan, in regard to the missed sepsis diagnosis, when it is your family member it counts.

*** When the MD missed ovarian cancer diagnosis after four visits and the NP caught it the first time she met my wife it counts too.

An fun as our own personal stories are to tell and read they don't prove anything.

+ Add a Comment