Make Advanced Practice Nurses Independent

Specialties NP

Published

Nurses need a more independent role, report argues - Health - Health care - msnbc.com

A new report released today may give nurses with advanced degrees a potent

weapon in their perennial battle to get the authority to practice without a

doctor's oversight.

Specializes in FNP.
Not all doctors oppose NP independence. In my graduating DNP cohort, as an example there are around 40 doctors (100%) in that class who all support NP independence and are chomping at the bit to act as transformational agents in the process of eliminating barriers to nursing practice as well as patients access to care. Next year, there will thousands of us...in five years, tens of thousands of doctors who will support NP independence and who will not stop until patients across the US have this artificial barrier to access removed.

The argument from organized medicine in that NP's can only deliver safe care if charts are signed by physicians a few days later and are available by phone (which constitutes supervision in many states) is rapidly dissolving. With the number of DNP programs and working DNP's being produced, organized medicine needs to come up with a different argument for maintaining a strangle hold on our practice while decreasing patients access to safe and affordable care.

Dr. T

Congratulations Dr. Tammy! You started the DNP the same time I started the FNP, but how did you finish in 3 semesters? Dr. Turner says it takes 5- you must have just blazed through. I am so impressed! Can you share a little about your capstone project? I start some of the DNP courses in May, but won't enter a cohort until August, and I've no idea what I want to research. I heard a few of the defenses in the Spring, but missed yours I guess. They were really impressive. I'm especially interested to hear about your experience at the legislature, that must really have been something. I had been wondering how it was going for you, and now I know why you didn't post -you were working your tail off to graduate a year early! Really, high 5.:yeah: You are an inspiration. I hope you will share some of your DNP education experience with those of us looking forward to it! There aren't enough DNPs here to empower and support us, I hope you'll pop back more often.

Let's talk about titles for a minute, and when it is approprite to use them. I have earned many formal titles over the years: Some from organizations (Scoutmaster), a gazillion from the military (Chief, Senior Chief, boatswain, Coxswain, OIC,, etc ad n auseum), a couple of educational titles (BS, MPH, and now MPAS-student), and a couple of medical ones (EMT, and MPAS-student).

So when is it appropriate for me to use these? I'm going to a funeral service Saturday for a soldier killed in Afghanistan so my military title will be appropriate to use there. If I refer to myself as 'Chief', most folks there will know what I'm talking about. But that title probably wouldn't be appropriate to use if I do a rotation on an indian reservation....the 'real' Chief there would, understandably, get pretty upset with me! Why? Not because I'm trying to BE an indian chief, but because somebody might perceive it that way.

Likewise. My title of Chief isn't appropriate in a hospital setting either. I certainly don't want anyone to confuse me with the Chief resident, or Chief of surgery.

The point I'm making here is that titles are supposed to be used to clarify roles, not confuse people. Yet this is exactly what will happen if a violin doctor walked into a hospital or clinic and introduced themselves as 'Doctor'....or if Nurse Tammy does the same.

Now, on a slightly different subject, I have a question for the 'Nurse Tammy's' if the world who expect/demand people to call them 'Doctor'. If you work with Masters level NPs...do you call them 'Master' in the work environment? No?? Why not??? I mean, they have a Masters Degree. Why shouldn't you call them master?

Wait, I already have an MPH - - so if I call you Doctor...will you call me Master?

Wait, wait, wait - this gets even better. I'll have TWO Masters when I get done w/PA school...so then you can call me 'Master Master'!!!

Or, how about we instill some common sense in this and stop confusing our patients (who would be really confused if they hear a doctor call someone their master - WOW!!). We let the HIGHLY trained physicians retain the title of 'Doctor' in medical settings, the PAs and NPs (whether they are masters, doctorates, or, in my case, a master-master) be PAs and NPs, and the nurses be nurses.

Specializes in Education, FP, LNC, Forensics, ED, OB.
Let's talk about titles for a minute, and when it is approprite to use them.

Let's not.

This is not the topic.

Please refrain from making these replies personal. More often than not, these threads get closed.

Please do not ignore this request.

Specializes in FNP.

I really, really don't understand why physicians would bother trolling allnurses. While you misunderstand quite a lot about the DNP, you don't seem sincere about wanting to gain a more thorough appreciation of it. Your presence here seems simply inflammatory, which makes you difficult to take seriously. I'd be delighted to have a scholarly discussion about the strengths and weaknesses of our health care system and the suggestions being put forth to address problems, including the DNP. I wouldn't be interested in any conversation that denigrated my life's purpose and passion, however.

Lineart - I don't see where anyone is denigrating NPs or nurses. We all know how important they are to the patients and to physicians. The issue here (and apparently it is verboten to stray from) is should NPs practice independently. Just because many of us don't think NPs should do this does NOT mean we do not value your roles.

Specializes in FNP.

I'm glad to heat that Boat. My post was directed to the person who says they are a physician; I gather from your user ID you are a PA student, which puts us in the same boat, as it were. Personally, I think the topic of supervision was already well covered with the observation that signing off charts at the end of the month is supervision in name only and serves no one any practical purpose (except for the individuals who profit from the exercise). I see no reason to continue with that farce, but if I must send my charts off for a rubber stamp, then I will comply. Let's just not pretend that makes anyone safer. Supervision, collaboration, it's all just politics and money. When I need support, I'll pick up the phone or write a referral, and this will be true no matter how independent I am permitted to be by my state legislature. Frankly, I don't know my state's present position, b/c as a new graduate NP it is going to be the furthest thing from my mind!

You make a great point. The current supervisory laws do not require a great deal of supervision. And it seems like only a small step from 'bare supervision' (ie - just blindly signing charts) to unsupervised practice.

However I think you are missing the benefits of such a flexible system. When you and I graduate there is no way in hell we should be unsupervised. I know I will seek out a SP who will watch over me relatively closely - hopefully in an ED or something. Furthermore, there shouldn't be a SP anywhere who would turn me loose on patients and just blindly sign my charts. With the 'unsupervised NP' model, however, you may find a 'boot' NP with minimal medical experience hanging her/his own shingle in independent practice...and this puts patients in danger.

Now, with the flexibility inherent in the current PA supervision model, those experienced PAs do NOT have to be babysat by physicians. I did a FP rotation with a PA yesterday who has been practicing for 35 years. He had 2 docs in his office as well, but he said they very rarely have to consult with each other. He is completely independent - except for the rubber-stamping of his charts by his SP.

I guess what I'm saying is the PA supervision scheme allows a progressive scale of autonomy for PAs, and let's the highly trained Doctors determine where on that scale 'their' are at. I think that is much better than either alternative (overly restrictive supervisory requirements or complete independence).

Specializes in ER; CCT.
Congratulations Dr. Tammy! You started the DNP the same time I started the FNP, but how did you finish in 3 semesters? Dr. Turner says it takes 5- you must have just blazed through. I am so impressed! Can you share a little about your capstone project? I start some of the DNP courses in May, but won't enter a cohort until August, and I've no idea what I want to research. I heard a few of the defenses in the Spring, but missed yours I guess. They were really impressive. I'm especially interested to hear about your experience at the legislature, that must really have been something. I had been wondering how it was going for you, and now I know why you didn't post -you were working your tail off to graduate a year early! Really, high 5.:yeah: You are an inspiration. I hope you will share some of your DNP education experience with those of us looking forward to it! There aren't enough DNPs here to empower and support us, I hope you'll pop back more often.

Thanks much and good to hear from you! Haven't posted for a bit because I've been so buried. I did kind of expedite the deal. I doubled down on two courses and transferred in one of my electives. I cleared committee on October 16, with none other than Dr. Turner (my hero and champion) as my chair! After I presented, she said to walk away for about 5 minutes so they could all vote. When I came back, she said "congrats Dr...!" I about fell over in my chair.

The legislative deal. Dr. Short (my other hero) got me interested in the activist process at the legislative level in her transformational courses. Everyone in the cohort had to select a topic and work through with advancing an issue. I had a hard time selecting one because there were so many to choose. It's funny, the anti-nursing comments from student doctor trolls on this site was one of my central motivating forces for selecting the topic of advancing nurse practitioner practice to exclude the artificial barrier of physician oversight.

To that end, after I produced an action plan video (which somehow got picked up by a half dozen nursing leaders throughout the US), presented my plan to three health care lobbyists at Duke, had two op eds published on the importance of independent NP practice, I found myself being requested to introduce and present my friend and mentor, Dr. Loretta Ford (the one and only) to our State NP conference to a standing ovation.

From that experience, coupled with the huge results and positive PR from my capstone in my community, I was approached by a large national non profit organization out of the blue (not related to health care, but having access to health care as a critical issue to the organizations constituents) and I was asked by their president to join the board of directors as their health chair! So, now I'm drafting, in collaboration with other NP's, forward thinking physicians and other members of the community, a resolution calling for the immediate dissolution of NP barriers to practice with research to support, and the positive consequences to select PARs as a result--with the full weight of this organization behind me!

Its kind of funny--if the student wannabe trolls would not have berated nurses, nursing and particularly advance practice nursing with such venom and complete disregard for our professional values and identity as an autonomous profession on this site, I probably would have chose third party reimbursement issues for NP's instead as my topic.

Take care,

Tammy

Specializes in ER; CCT.
You make a great point. The current supervisory laws do not require a great deal of supervision. And it seems like only a small step from 'bare supervision' (ie - just blindly signing charts) to unsupervised practice.

Good observation. Follow that line of thinking. Ask yourself these questions:

1. Is the nursing profession owned by physicians and the profession of medicine?

2. Is nursing a separate profession than medicine?

3. Do other independent health care professions that have overlapping functions (such as diagnosing and/or prescribing) fall under the control of medicine and physicians (i.e. dentistry, optometry, podiatry, psychology, pharmacy)?

4. Does nursing, as an independent and autonomous profession, fall under the control of medicine?

5. Do physicians and the profession of medicine have control over everything related to any topic or profession within the health care industry?

6. In regards to mandatory supervision of NP's by way of MD's signing NP charts days later, who is actually served by these regulations--from a financial, political and power point of view? Keep in mind that the consumer is protected by licensing boards and NP's are compromised as this directly involves barriers to practice.

As nurses, we need to understand that if we do not stand up and take ownership of our profession and direct our future--others outside of nursing will be more than happy to do it for us. True, the arrogance in one profession attempting to dominate another profession is readily apparent--but this can only happen if we let it.

Tammy

Specializes in FNP.
You make a great point. The current supervisory laws do not require a great deal of supervision. And it seems like only a small step from 'bare supervision' (ie - just blindly signing charts) to unsupervised practice.

However I think you are missing the benefits of such a flexible system. When you and I graduate there is no way in hell we should be unsupervised. I know I will seek out a SP who will watch over me relatively closely - hopefully in an ED or something. Furthermore, there shouldn't be a SP anywhere who would turn me loose on patients and just blindly sign my charts. With the 'unsupervised NP' model, however, you may find a 'boot' NP with minimal medical experience hanging her/his own shingle in independent practice...and this puts patients in danger.

Now, with the flexibility inherent in the current PA supervision model, those experienced PAs do NOT have to be babysat by physicians. I did a FP rotation with a PA yesterday who has been practicing for 35 years. He had 2 docs in his office as well, but he said they very rarely have to consult with each other. He is completely independent - except for the rubber-stamping of his charts by his SP.

I guess what I'm saying is the PA supervision scheme allows a progressive scale of autonomy for PAs, and let's the highly trained Doctors determine where on that scale 'their' are at. I think that is much better than either alternative (overly restrictive supervisory requirements or complete independence).

I agree that as a new grad NP, I will be nowhere near capable of independent practice. I will not be someone with mere rubber stamping of my charts for quite a long while, lol. I'm really hoping to find a strong mentor! However, we part ways when we look some distance down the road. I am acquainted with NPs more than capable of independent practice, and whom are, in fact, already practicing independently in all but name. I know one that owns and operates her own practice and the physician works for her, merely auditing and signing the minimum number of charts. This is ludicrous and I do not see any rational reason for NPs to pay a physician to sign off on their charts. I say allow NPs to govern their practice the same way physicians do and dispense with this supervision myth. New grad NPs can be mentored by experienced NPs, or physicians if we choose.

in regards to mandatory supervision of np's by way of md's signing np charts days later, who is actually served by these regulations--from a financial, political and power point of view? keep in mind that the consumer is protected by licensing boards and np's are compromised as this directly involves barriers to practice.

as nurses, we need to understand that if we do not stand up and take ownership of our profession and direct our future--others outside of nursing will be more than happy to do it for us. true, the arrogance in one profession attempting to dominate another profession is readily apparent--but this can only happen if we let it.

tammy

ironic you allude to doctors as being the ones who are arrogant. now which group is it that is taking a short cut around tens of thousands of hours of clinical training, scores of hours of hard sciences and years of residency and then calls themselves equivalent? explain to me which group is arrogant- the people taking the short cuts or the ones calling them out on it.

personally i think that nps should have closer supervision. i agree chart reviews days later does next to nothing; regulations should be tighter such that an np should have to present to an attending after each case just we had to do in during resident clinic.

Specializes in FNP.

Due respect doctor, that's just ridiculous.

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