In Support of Independent NP Practice

Specialties NP

Published

Ahhh, the need for care in highly urbanized cities vs the sticks. Both areas need healthcare obviously. But agree that there is a great need in urban areas that NP's have actually filled. Great example: City and County of San Francisco - such a sharp contrast of rich and poor, a city with one of the highest numbers of millionaires living within its borders yet hides a nasty secret of poverty inside its ghettos. Not surprisingly, it is a nurse-practitioner managed clinic that is present in the most crime-ridden, poverty-stricken, drug infested neighborhood of "The Tenderloin". Meanwhile, "boutique clinics" and concierge medical services have sprung up in yuppie neighborhoods with residents of the Silicon Valley types. Not surprisingly, NP's have also been hired in those places. Link to this: Glide Methodist Church Healthcare Services.

I can show this too in a very well known and large inner city. I did required clinical stint at this great place for a particular program. The NPs and social workers have done a great job. Absolutely! Guess what? The NP director had enough sense to know the value of getting support and physicians on the board and in support of their program. This has only strengthened their outreach in the community. There wasn't this, "Every discipline for themselves" kind of approach.

Communities will never get what they need if disciplines continue to function apart from a collective unity, which includes physicians.

Oh I totally agree! I wouldn't dare think of going independent as a new NP and quite frankly not after multiple years of experience! That would totally be a bad recipe for disaster.

Specializes in ER, HH, CTICU, corrections, cardiology, hospice.

Susie2310, a lot of what you say no one is arguing. We are not MD's and I am quick to correct anyone that addresses me as such. Personally I don't favor NP's being addressed as "doctor" in the clinical setting. Not an issue you raised though. I have caught things missed by MDs on occasion. Have I missed things, probably, I pray the patient wasnt harmed. To date none have been. The point being, mistakes happen, it's an imperfect world. I hope your family member recovered, if not, I hope your pain heals.

My colleages have provided studies that prove our point. Neither you nore samadams8 have presented any studies at all. You are working off of a visceral impulse, which doesn't carry a lot of weight in rhetoric.

BostonFNP, we most certainly do practice medicine. Sorry but it is the truth. I have never written a prescription based on a nursing diagnosis. No NP I know of has ever written a prescription based off of a nursing diagnosis.

I am for independant practice. I personally would not practice solo if I could help it. I don't know everything so I ask my colleages frequently or uptodate. I like to think that what makes me a good provider is I check my ego and if I have a doubt, I ask. My patients are worth more to me than my pride. There are people I will freely consult and those I would rather French kiss a light socket than ask, but I will.

If you do not want to see an AdvancedPpracticeProvider. Don't. I doesn't hurt my feelings one iota. I have a gracious plenty of patients as it stands, one more or less makes no differance in my workload.

As usual, Juan is spot on. He could sell sand to a Bedouin.

I would suggest that it protects patients. Again, what is wrong with having sound oversight with physicians. Where's the team effort?

Do you have any actual evidence that demonstrates that these laws protect patients? I ask because, as has already been made very clear, these laws vary widely. How does chart review two times a year protect patients? NPs already collaborate, they don't need to be told to do so. All these laws do is hamper NP practice and patent access to care and/or cause them to be reimbursed less because someone else is cutting into their profits.

Specializes in Family Practice, Primary Care.

Maybe it should go both ways with oversight.

I will be graduating in a few weeks from my NP program. My S.O. was seen by an MD who based off a CBC decided he was iron deficient and should take iron supplementation. He's 26. It is pretty unusual for a 26 year old male to be iron deficient. I asked if she'd do iron studies before recommending supplementation since he could have a genetic defect such as beta thalassemia, and she outright refused and was certain she was right.

I went to another provider and got the labs ordered. He wasn't iron deficient, and I was right. And iron supplementation with someone with beta thal minor can cause hemochromatosis. An NP student out-thought an MD, with her 4 years of med school and residency. So yeah, clinical hours and education do not necessarily equal a better provider.

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
I can show this too in a very well known and large inner city. I did required clinical stint at this great place for a particular program. The NPs and social workers have done a great job. Absolutely! Guess what? The NP director had enough sense to know the value of getting support and physicians on the board and in support of their program. This has only strengthened their outreach in the community. There wasn't this, "Every discipline for themselves" kind of approach.

Communities will never get what they need if disciplines continue to function apart from a collective unity, which includes physicians.

Is there anyone on this thread that advocated for "every discipline for themselves" kind of approach? If anything, you're the only one insinuating that NP's who are in support of independent practice will never consult or collaborate with a physician ever.

It is plain presumptive to say that having a physician on board will strengthen nurse-managed health centers' outreach to the community. Many NMHC's serve a population that has been marginalized and could care less if a physician shows up to provide their care. Physician presence in those places serve as a token reminder of the need for a piece of paper signed as a collaborative agreement in states where it is required, nothing more nothing less. It is these bureaucratic regulations that push these places from financial sustainability given the type of patients they serve.

Look, it's going to be hard to convince you to change your views and nobody is trying to convert you. It's a free country, you can choose to believe how you want to and this forum is no exception. But you have not convinced me either that independent practice for NP's is unsafe.

Is there anyone on this thread that advocated for "every discipline for themselves" kind of approach? If anything, you're the only one insinuating that NP's who are in support of independent practice will never consult or collaborate with a physician ever.

It is plain presumptive to say that having a physician on board will strengthen nurse-managed health centers' outreach to the community. Many NMHC's serve a population that has been marginalized and could care less if a physician shows up to provide their care. Physician presence in those places serve as a token reminder of the need for a piece of paper signed as a collaborative agreement in states where it is required, nothing more nothing less. It is these bureaucratic regulations that push these places from financial sustainability given the type of patients they serve. .

"It is plain presumptive to say that having a physician on board will strengthen nurse-managed health centers' outreach to the community. Many NMHC's serve a population that has been marginalized and could care less if a physician shows up to provide their care. Physician presence in those places serve as a token reminder of the need for a piece of paper signed as a collaborative agreement in states where it is required, nothing more nothing less."

OK, WOW, now that is presumptive. And the comment only supports my position that you sought to contradict. That's kind of sad, and it backs up this whole "I'm the receiver making the touch down, and the other players are secondary" mentality. It's a political agenda, and there is already enough "Every discipline for himself/herself" in healthcare. People are right about one thing though; the patients pay the price.

Absolutely getting physicians on board is vital. That you can't see this though, without somehow feeling emotionally abraised, is striking and supports another previous point I made in this thread.

People have lost sight of the fact that it's not supposed to be all about the clinician. It's supposed to be about the patients and society as a whole.

It doesn't matter to me if you want to downplay the importance of physicians in healthcare practice. At it doesn't matter to me if some cannot get passed the absolute reality that healthcare includes medicine, and advanced practice nurses or PAs, etc, practice on one level or another, look out, yes, medicine.

Look, I remember that you made an intelligent response to a condition and physiological response to something a few weeks back. Dude, it was flat out excellent. And to be completely honest, my colleagues and I in critical care, at least in the units we were/are working in, were/are thinking upon the science in the very same way. We were/are experienced critical care nurses who delve/d deeper. We were not advanced practice nurses. But it doesn't matter; b/c when were thinking and approaching things in that way, we were thinking like medicine. Now, of course legally, we had to go through the proper channels for treatment purposes, but most of the physicians respected us for thinking on that level--and they even came/have come to expect it from certain of us. The point is, in thinking that way and then acting upon that thinking process and approach, with the appropriate data in hand, it moved beyond the nursing process. It involved, at its core, medicine. Now,we weren't practicing medicine, b/c we went through appropriate physician channels for the necessary orders. There can often me this fine line. When you move into advanced practice nursing, now, you are not only expected to think like this, you are expected to intervene in such a way that in actuality is medical practice.

The story can't stop there. Here's why. Regardless, it's not the same thing as going through the whole process of medical education, residency, and possibly a fellowship--not even close in terms of clinical experience and exposure--not close in terms of depth of education--not close in the many hoops and vetting processes required to become a physician and regulary practice medicine.

I am not interested in trying to change your mind. The probability is that rather than stepping back and looking at this thing from another perspective--a bigger perspective, you have decided that you are on "Team NP." And that's fine! Go team! But it doesn't change the nature of what someone is doing at their core level, even if their profession's over approach, philosophy, and theories are different. At the end of the day, many of advanced practiced functions are,in reality, medicine, only at a more fundamental level. Sure there are differences, but such functions in most settings involve medical knowledge and practice. It's impossible to get around that core reality.

I say, with regard to the whole situation, it will play out with the many current and forthcoming changes in healthcare, and we will see where it goes.

I say, it depends on the patient, his/her whole history, as well as her/his current condition, which may well direct the client as to which practitioner to see. I also say that medicine needs to do a better job at filling those rural healthcare needs.

BTW, I am not telling people who to see or who to not see. I believe in freedom, and at the end of the day, I don't really care, except as it pertains to my health and wellness and that of my loved ones, based on their/my particular needs. I say this, b/c people have choices, so let them choose.

I'm currently not politically active on either side of this on-going debate. The biggest thing I have to say with regard to advanced practice nursing is that these programs should not allow entry of those with

Other than that, no. I am not losing sleep over this.

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Physician presence in those places serve as a token reminder of the need for a piece of paper signed as a collaborative agreement in states where it is required, nothing more nothing less."
Can you prove to me that this statement is not true? I want actual physician accounts of how NP's are "supervised" in those places and exactly what input they give to each patient encounter. Without that data, I have to believe my statement to be true. And no, your critical care experience that you keep bringing up in this purely "primary care" discussion does not count.

People are right about one thing though; the patients pay the price.
How? by not allowing access to care from NP's.

Absolutely getting physicians on board is vital. That you can't see this though, without somehow feeling emotionally abraised, is striking and supports another previous point I made in this thread.

I am not emotionally abraised. I'm actually trying to be really rational about this.

People have lost sight of the fact that it's not supposed to be all about the clinician. It's supposed to be about the patients and society as a whole.

That statement sounds like a case for NP independence and you just said it.

It doesn't matter to me if you want to downplay the importance of physicians in healthcare practice. At it doesn't matter to me if some cannot get passed the absolute reality that healthcare includes medicine, and advanced practice nurses or PAs, etc, practice on one level or another, look out, yes, medicine.
Yeah, that's true. There's overlap between Medicine and Advanced Practice Nursing. But that happened 40 years ago when the nurse practitioner role was born. That's not new so you'll just have to accept it.

Look, I remember that you made an intelligent response to a condition and physiological response to something a few weeks back. Dude, it was flat out excellent. And to be completely honest, my colleagues and I in critical care, at least in the units we were/are working in, were/are thinking upon the science in the very same way. We were/are experienced critical care nurses who delve/d deeper. We were not advanced practice nurses. But it doesn't matter; b/c when were thinking and approaching things in that way, we were thinking like medicine. Now, of course legally, we had to go through the proper channels for treatment purposes, but most of the physicians respected us for thinking on that level--and they even came/have come to expect it from certain of us. The point is, in thinking that way and then acting upon that thinking process and approach, with the appropriate data in hand, it moved beyond the nursing process. It involved, at its core, medicine. Now,we weren't practicing medicine, b/c we went through appropriate physician channels for the necessary orders. There can often me this fine line. When you move into advanced practice nursing, now, you are not only expected to think like this, you are expected to intervene in such a way that in actuality is medical practice.

Well, I work in crititcal care as a nurse practitioner so there's a difference between you making judgments based on medical concepts and myself as a nurse practitioner, fully credentialed by the academic medical center, who can write orders and intervene accordingly. And that is completely legal in the State of California by the way. But again, my thread is not about critical care, it's about primary care.

The story can't stop there. Here's why. Regardless, it's not the same thing as going through the whole process of medical education, residency, and possibly a fellowship--not even close in terms of clinical experience and exposure--not close in terms of depth of education--not close in the many hoops and vetting processes required to become a physician and regulary practice medicine.

Keep reverting to this argument that no one is questioning anyway.

I am not interested in trying to change your mind. The probability is that rather than stepping back and looking at this thing from another perspective--a bigger perspective, you have decided that you are on "Team NP." And that's fine! Go team! But it doesn't change the nature of what someone is doing at their core level, even if their profession's over approach, philosophy, and theories are different. At the end of the day, many of advanced practiced functions are,in reality, medicine, only at a more fundamental level. Sure there are differences, but such functions in most settings involve medical knowledge and practice. It's impossible to get around that core reality.

OK

I say, with regard to the whole situation, it will play out with the many current and forthcoming changes in healthcare, and we will see where it goes.

Yep

I say, it depends on the patient, his/her whole history, as well as her/his current condition, which may well direct the client as to which practitioner to see. I also say that medicine needs to do a better job at filling those rural healthcare needs.

Yep

BTW, I am not telling people who to see or who to not see. I believe in freedom, and at the end of the day, I don't really care, except as it pertains to my health and wellness and that of my loved ones, based on their/my particular needs. I say this, b/c people have choices, so let them choose.

Yep

I'm currently not politically active on either side of this on-going debate. The biggest thing I have to say with regard to advanced practice nursing is that these programs should not allow entry of those with

Save that for another thread.

Specializes in Adult Internal Medicine.

We were/are experienced critical care nurses who delve/d deeper. We were not advanced practice nurses. But it doesn't matter; b/c when were thinking and approaching things in that way, we were thinking like medicine. Now, of course legally, we had to go through the proper channels for treatment purposes, but most of the physicians respected us for thinking on that level--and they even came/have come to expect it from certain of us.

The biggest thing I have to say with regard to advanced practice nursing is that these programs should not allow entry of those with

This is actually a documented phenomenon in the role socialization literature for advanced practice: role resistance. It, perhaps, explains some of your disdain for advanced practice. I can both understand and appreciate that on a personal level. On a professional level it is very different, as critical care experience does not translate directly to primary care, in fact the literature shows it actually impedes role transition.

Specializes in Peds/outpatient FP,derm,allergy/private duty.
This is actually a documented phenomenon in the role socialization literature for advanced practice: role resistance. It, perhaps, explains some of your disdain for advanced practice. I can both understand and appreciate that on a personal level. On a professional level it is very different, as critical care experience does not translate directly to primary care, in fact the literature shows it actually impedes role transition.

Curious about this concept of "role resistance" but I searched both regular Google and Google Scholar and didn't find anything. Can you point me in the right direction here?

Also curious - if the most oft-mentioned requirement and/or recommendation for entry to an NP program is 1-2 years ICU experience, and you are saying this actually impedes the NP student, what would you suggest the nursing part of nurse practitioner consist of, if anything?

Let me say that I'm not flatly opposed to direct-entry due to knowing some fine direct-entry NPs here on this forum but I think there is a legitimate discussion to be had on the subject nonetheless.

I'm sorry, but I don't understand how 5 years of ICU experience (compared with other kinds of nursing experience or even a new grad) translates to higher quality FNPs that work in outpatient settings providing primary care. That seems like a very arbitrary condition to make. This is the problem with nursing, IMO. There are too many people who think things should be based on their personal opinion/personal experience, "gut feeling" or whatever, instead of actually looking at what the data says.

Specializes in Adult Internal Medicine.

Curious about this concept of "role resistance" but I searched both regular Google and Google Scholar and didn't find anything. Can you point me in the right direction here?

Also curious - if the most oft-mentioned requirement and/or recommendation for entry to an NP program is 1-2 years ICU experience, and you are saying this actually impedes the NP student, what would you suggest the nursing part of nurse practitioner consist of, if anything?

Let me say that I'm not flatly opposed to direct-entry due to knowing some fine direct-entry NPs here on this forum but I think there is a legitimate discussion to be had on the subject nonetheless.

I apologize to Juan as this is going off-topic.

It has been discussed in several studies, off the top of my head take a look at Rich et al (2005) and Steiner (2008). I know there are at least two studies that will be coming out in the next few months that have also addressed this issue.

The ICU experience requirement relates most often to CRNA education which I can't speak to. In terms of NP education (save for ACNP perhaps) there does not appear to be a significant benefit to prior nursing experience based on several studies, though I have never seen a study that has addressed critical care experience in isolation.

On the other hand, I think just about every study has identified there is value to experience, especially qualitatively. It is unclear in the lit if this is somehow balanced by what has been termed "role confusion". The quantitative results do not seem to reflect the qualitative, though there is some disagreement there.

As far as my own personal thoughts, I would push for a drastic change in DE education. Typically these programs are 50/50 RN and NP. I would actually change this to a 25/75 split, increasing graduate clinic hours, focusing the majority of education on the advance practice role. I feel like there are myriad of benefits in this shift. In all honesty, I would have never though this way before I went through grad education and got out to practice as a NP in primary care.

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